May 31, 2008
Great Vial Experiment Appears to be a Bust
Levermir placed in the purchased sterile vial appears to get cloudly and lose potency after 3 days. So perhaps what the pharmacist told me, that they coat the vials with something special, is true.
May 28, 2008
Insulin Right After Diagnosis Dramatically Improves Type 2 Outcome
Two studies just published in the journal Lancet show you just how mistaken is the current practice of starting Type 2s on oral drugs and withholding insulin until their A1c with a full load of oral drugs is 10% or higher.
These are the studies:
Effect of intensive insulin therapy on β-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: a multicentre randomised parallel-group trial. Jianping Weng et al. The Lancet 2008; 371:1753-1760
and
Intensive insulin therapy in newly diagnosed type 2 diabetes. Ravi Retnakaran and Daniel J Drucker. Lancet 2008; 371:1725-1726. (Subscription required)
In the first study, "The patients, with fasting plasma glucose of 7·0–16·7 mmol/L [126 - 300] , were randomly assigned to therapy with insulin (CSII [pump] or MDI [basal/bolus shots]) or oral hypoglycaemic agents [oral drugs] for initial rapid correction of hyperglycaemia. Treatment was stopped after normoglycaemia [normal blood sugar] was maintained for 2 weeks. Patients were then followed-up on diet and exercise alone."
Here's what happened:
"A year after stopping therapy, the remission rate was 42% among those who reached normal blood glucose levels during the treatment period, the researchers said.
But the rates were 51.1% among those who were treated with insulin infusion, 44.9% among those given insulin injections, and only 26.7% in the oral hypoglycemic agents group."
What this means is that almost twice as many newly diagnosed people with Type 2 diabetes who received intensive insulin treatment right after diagnosis were able to achieve normal blood sugars using only diet and exercise than did the people treated only with oral drugs. Even though the patients given insulin were taken off insulin after experiencing only two weeks of normal blood sugars!
This is a monumental finding and one that should make you insist that your doctor give you a basal/bolus insulin regimen as soon as you are unable to maintain normal blood sugars with diet and exercise alone. If you can't get truly normal blood sugars by cutting the carbs and increasing your physical activity, skip the expensive and ineffective oral drugs and go to the drug that always lowers blood sugar: insulin.
Why does insulin work so much better than other drugs?
The answer is probably because it is the only drug that reliably drops blood sugars below the level that cause secondary insulin resistance. Many doctors do not seem to understand that if your blood sugar is high the high blood sugar itself causes insulin resistance no matter what your underlying physiology might be. And this additional blood-sugar related insulin resistance starts at relatively low levels--much lower than doctors understand. I personally see a huge difference in my insulin resistance after meals--measured by how much insulin I need to cover a given number of carbs--when my fasting blood sugar is 108 mg/dl and when it is 85 mg/dl.
But when you take an oral drug that does a feeble job of lowering your blood sugar, you have to contend not only with the damage caused by the too-high blood sugar, but also with the additional insulin resistance caused by your too-high blood sugars. This IR packs on additional pounds and hastens the burnout of your insulin producing beta cells because they must make much more insulin to cover the meals you eat.
A telling fact that came out at the recent AACE conference that got no play in the media at all is that in the last decades the average A1c of people with diabetes in America has risen dramatically.
As reported in the Endocrinology Today newsletter: "Between 1988 and 1994, NHANES data reported 44.5% of patients reaching a target HbA1c of 7.0% or less. Between 1999 and 2000, that percentage dropped to 35.8%."
The reason fort this? The endocrinologists scratch their head but admit that with the greater choice of oral drugs, fewer patients are using diet to control blood sugar. And though the article doesn't spell this out, it is also likely that because there are so many new, expensive, highly promoted oral drugs, doctors are delaying the move to insulin for much longer than they did in the late 80s when they had few oral drugs to try and moved to insulin faster. The article does report, "Insulin use in the United States remains low."
Doctors like oral drugs because they don't have to follow up with patients, educate them, or worry about hypos. Drug company reps make it sound like their drugs can provide healthy blood sugars, even though the prescribing information (that doctors rarely read) shows that most lower A1c by no more than 1% and many by only .5%--in patients whose blood sugar starts at levels of 8% or higher.
Until now we had vague information suggesting that using insulin immediately after diagnosis could preserve the beta cell function of people with LADA. Now, with this new data, we see that using insulin right after diagnosis benefits Type 2s, too.
So don't let your doctor tell you that it's better to try all of the many oral drugs before you start insulin. It isn't true, and waiting three or four years while taking drugs that can't normalize your blood sugar may mean that by the time you start insulin you have few beta cells left to save.
These are the studies:
Effect of intensive insulin therapy on β-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: a multicentre randomised parallel-group trial. Jianping Weng et al. The Lancet 2008; 371:1753-1760
and
Intensive insulin therapy in newly diagnosed type 2 diabetes. Ravi Retnakaran and Daniel J Drucker. Lancet 2008; 371:1725-1726. (Subscription required)
In the first study, "The patients, with fasting plasma glucose of 7·0–16·7 mmol/L [126 - 300] , were randomly assigned to therapy with insulin (CSII [pump] or MDI [basal/bolus shots]) or oral hypoglycaemic agents [oral drugs] for initial rapid correction of hyperglycaemia. Treatment was stopped after normoglycaemia [normal blood sugar] was maintained for 2 weeks. Patients were then followed-up on diet and exercise alone."
Here's what happened:
"A year after stopping therapy, the remission rate was 42% among those who reached normal blood glucose levels during the treatment period, the researchers said.
But the rates were 51.1% among those who were treated with insulin infusion, 44.9% among those given insulin injections, and only 26.7% in the oral hypoglycemic agents group."
What this means is that almost twice as many newly diagnosed people with Type 2 diabetes who received intensive insulin treatment right after diagnosis were able to achieve normal blood sugars using only diet and exercise than did the people treated only with oral drugs. Even though the patients given insulin were taken off insulin after experiencing only two weeks of normal blood sugars!
This is a monumental finding and one that should make you insist that your doctor give you a basal/bolus insulin regimen as soon as you are unable to maintain normal blood sugars with diet and exercise alone. If you can't get truly normal blood sugars by cutting the carbs and increasing your physical activity, skip the expensive and ineffective oral drugs and go to the drug that always lowers blood sugar: insulin.
Why does insulin work so much better than other drugs?
The answer is probably because it is the only drug that reliably drops blood sugars below the level that cause secondary insulin resistance. Many doctors do not seem to understand that if your blood sugar is high the high blood sugar itself causes insulin resistance no matter what your underlying physiology might be. And this additional blood-sugar related insulin resistance starts at relatively low levels--much lower than doctors understand. I personally see a huge difference in my insulin resistance after meals--measured by how much insulin I need to cover a given number of carbs--when my fasting blood sugar is 108 mg/dl and when it is 85 mg/dl.
But when you take an oral drug that does a feeble job of lowering your blood sugar, you have to contend not only with the damage caused by the too-high blood sugar, but also with the additional insulin resistance caused by your too-high blood sugars. This IR packs on additional pounds and hastens the burnout of your insulin producing beta cells because they must make much more insulin to cover the meals you eat.
A telling fact that came out at the recent AACE conference that got no play in the media at all is that in the last decades the average A1c of people with diabetes in America has risen dramatically.
As reported in the Endocrinology Today newsletter: "Between 1988 and 1994, NHANES data reported 44.5% of patients reaching a target HbA1c of 7.0% or less. Between 1999 and 2000, that percentage dropped to 35.8%."
The reason fort this? The endocrinologists scratch their head but admit that with the greater choice of oral drugs, fewer patients are using diet to control blood sugar. And though the article doesn't spell this out, it is also likely that because there are so many new, expensive, highly promoted oral drugs, doctors are delaying the move to insulin for much longer than they did in the late 80s when they had few oral drugs to try and moved to insulin faster. The article does report, "Insulin use in the United States remains low."
Doctors like oral drugs because they don't have to follow up with patients, educate them, or worry about hypos. Drug company reps make it sound like their drugs can provide healthy blood sugars, even though the prescribing information (that doctors rarely read) shows that most lower A1c by no more than 1% and many by only .5%--in patients whose blood sugar starts at levels of 8% or higher.
Until now we had vague information suggesting that using insulin immediately after diagnosis could preserve the beta cell function of people with LADA. Now, with this new data, we see that using insulin right after diagnosis benefits Type 2s, too.
So don't let your doctor tell you that it's better to try all of the many oral drugs before you start insulin. It isn't true, and waiting three or four years while taking drugs that can't normalize your blood sugar may mean that by the time you start insulin you have few beta cells left to save.
May 25, 2008
New Widget Converts A1c/Glucose/mg/dl/mmol/L
I had some spare time this morning and turned my A1c/Avg converter into a widget you can put on your own blog or web pages. It will convert A1c to average blood sugar and vice versa using either mg/dl or mmol/L. You can also use it to convert mmol/L and mg/dl back and forth. Enter one measurement, and the converter will fill in the others.
This converter uses the most recent ADAG formula which was just published this past fall. It is based on a large number of CGMS measurements and is supposed to be more accurate than the old DCCT formula which is the one most commonly used. That's because the DCCT formula was derived from infrequent meter testing. I find this formula gives a lower equivalent than the DCCT formula. And to me it appears more accurate.
You will find the new widget at Widgetbox.com HERE
Give it a try and let me know what you think. Also let me know if you have a problem displaying it on your screen. I've tested it on our computers but there may be problems with some screen sizes and fonts.
If you want to install it on a page of your own, click the "get widget" link and past the code into your own page. In blogger, use the "Layout" feature and create a new "HTML/Javascript" item.
I've also added a "Recent Posts" widget which shows more posts by title than the Blogger Archive does. The archive is now at the bottom of the page.
This converter uses the most recent ADAG formula which was just published this past fall. It is based on a large number of CGMS measurements and is supposed to be more accurate than the old DCCT formula which is the one most commonly used. That's because the DCCT formula was derived from infrequent meter testing. I find this formula gives a lower equivalent than the DCCT formula. And to me it appears more accurate.
You will find the new widget at Widgetbox.com HERE
Give it a try and let me know what you think. Also let me know if you have a problem displaying it on your screen. I've tested it on our computers but there may be problems with some screen sizes and fonts.
If you want to install it on a page of your own, click the "get widget" link and past the code into your own page. In blogger, use the "Layout" feature and create a new "HTML/Javascript" item.
I've also added a "Recent Posts" widget which shows more posts by title than the Blogger Archive does. The archive is now at the bottom of the page.
May 22, 2008
The Great Vial Experiment
I use very small doses of basal insulin. No more than 2.5 units a day.
But though I've been able to make an insulin pen last long enough to use up every drop of insulin in it, my experience with vials over the past several years has been that the insulin in them always goes bad, no matter what I do to try to keep them alive.
I've tried all of the following: Alway using a new syringe, wiping the top with alcohol, and refrigerating the vial with a thermometer near it to make sure it isn't getting too cold. It doesn't matter. Insulin from the vial always starts to weaken after about six weeks and my blood sugars start creeping up. If I get a new vial, it's immediately very clear how weak my old vial was and if my doses have been creeping up I can have an interesting day the first time I use the new vial.
Pens don't do this even when I reuse pen needles, and my guess is it has something to do with the pressure inside the pen which pushes anything in the needle out before it can enter the insulin container and contaminate it.
Whatever the explanation, my current insurer charges the top copay--$50--for a vial of the kinds of insulin I'm using and won't cover pens without a long and complicated appeal put in by my endocrinologist. I don't like to use pens for the basal anyway, as I use fractional doses and I don't trust the pen to dispense 1 unit accurately. So when I bought my latest expensive vial of Levemir, I decided to try an experiment to see if I could keep the insulin in the vial alive for a longer time.
What I did was mail order some sterile 10 ml vials and transfer 100 units of insulin into the new sterile vial. I'm going to draw the insulin from that sterile vial, not the manufacturer's vial and thus cut way down on the number of times I introduce a needle into the main vial. Hopefully this means I'll be able to use all of those 1,0000 units instead of only 150 or so.
Another benefit of this approach compared to pens is that I won't be wasting the many air shots I have to waste when I use pens. The air shots can use up even more insulin than my basal shots. The convenience of the pen is a huge issue with post-meal insulin, but not for basal.
I'll be reporting back in a few months about whether this strategy is effective. If any of you who use tiny doses have any other suggestions about how to keep insulin in vials alive. Let me know.
UPDATE: 5/24/08
The insulin in the mail order vial is still working as it should. The only problem I've run into is that my syringes are dulling out much faster than they do I've been reusing them with a manufacturer's pen. This is probably because the rubber seal on the mail order vial is made out of a cheaper material.
The result is that the shots will hurt and bruise if I don't change the needle after no more than 2 shots.
NOTE: I have tried not reusing needles and reusing needles and have not seen any difference in how well my insulin holds up. When I reuse a syringe I do not inject air into the vial and I carefully expel any insulin left in the needle squirt-gun style after each use. Periodically I bleed the air out of the syringe by inserting a new needle with the plunger removed. This is the procedure described in the book, Dr. Bernstein's Diabetes Solution.
But though I've been able to make an insulin pen last long enough to use up every drop of insulin in it, my experience with vials over the past several years has been that the insulin in them always goes bad, no matter what I do to try to keep them alive.
I've tried all of the following: Alway using a new syringe, wiping the top with alcohol, and refrigerating the vial with a thermometer near it to make sure it isn't getting too cold. It doesn't matter. Insulin from the vial always starts to weaken after about six weeks and my blood sugars start creeping up. If I get a new vial, it's immediately very clear how weak my old vial was and if my doses have been creeping up I can have an interesting day the first time I use the new vial.
Pens don't do this even when I reuse pen needles, and my guess is it has something to do with the pressure inside the pen which pushes anything in the needle out before it can enter the insulin container and contaminate it.
Whatever the explanation, my current insurer charges the top copay--$50--for a vial of the kinds of insulin I'm using and won't cover pens without a long and complicated appeal put in by my endocrinologist. I don't like to use pens for the basal anyway, as I use fractional doses and I don't trust the pen to dispense 1 unit accurately. So when I bought my latest expensive vial of Levemir, I decided to try an experiment to see if I could keep the insulin in the vial alive for a longer time.
What I did was mail order some sterile 10 ml vials and transfer 100 units of insulin into the new sterile vial. I'm going to draw the insulin from that sterile vial, not the manufacturer's vial and thus cut way down on the number of times I introduce a needle into the main vial. Hopefully this means I'll be able to use all of those 1,0000 units instead of only 150 or so.
Another benefit of this approach compared to pens is that I won't be wasting the many air shots I have to waste when I use pens. The air shots can use up even more insulin than my basal shots. The convenience of the pen is a huge issue with post-meal insulin, but not for basal.
I'll be reporting back in a few months about whether this strategy is effective. If any of you who use tiny doses have any other suggestions about how to keep insulin in vials alive. Let me know.
UPDATE: 5/24/08
The insulin in the mail order vial is still working as it should. The only problem I've run into is that my syringes are dulling out much faster than they do I've been reusing them with a manufacturer's pen. This is probably because the rubber seal on the mail order vial is made out of a cheaper material.
The result is that the shots will hurt and bruise if I don't change the needle after no more than 2 shots.
NOTE: I have tried not reusing needles and reusing needles and have not seen any difference in how well my insulin holds up. When I reuse a syringe I do not inject air into the vial and I carefully expel any insulin left in the needle squirt-gun style after each use. Periodically I bleed the air out of the syringe by inserting a new needle with the plunger removed. This is the procedure described in the book, Dr. Bernstein's Diabetes Solution.
May 20, 2008
How the Blood Sugar 101 Book is Doing
Well, it's been about two months since my book came out, and I've been really happy with the reception. I have gotten a lot of email from buyers who found it very helpful, and their words have been really heartening. A few have told me they went on to buy copies for friends and relatives and some bought copies for their local libraries. Thanks so much to all of you!
Just last week I got a letter from my hero, Dr. Richard K. Bernstein. I'd sent him a copy at the suggestion of Steve Freed of Diabetes in Control after he published a very positive review of the book. But I didn't expect to hear back from Dr. Bernstein since I take a very different approach to diet than he does and because I knew he was still enthusiastic about TZD drugs which I write are dangerous for people with diabetes.
So imagine my surprise when I opened his letter and read that the enjoyed Blood Sugar 101 and believed it contained information available nowhere else and that people with diabetes should read it! I've written to ask him if I can quote what he wrote and until I hear from him, I won't cite his exact words, but you better believe I was walking on air for a few days after I got that letter!
The challenge with marketing this kind of book is that because I'm not a doctor and because the book is published by a small press, I can't go on the radio or TV to promote it, and the book chains won't stock it on their shelves. So that means I pretty much have to rely on whatever word of mouth recommendations I can stimulate to get people to buy it from the online bookstores where it is available.
So that leads to this blatant plea for your help. If you have read Blood Sugar 101 and have found it helpful, let people know. Also, ask your local public library to stock it. It is available from Baker & Taylor, the company that sells to libraries, and most libraries will order books that patrons ask for.
If you have any other ideas for how we can get more people reading this book, let me know. Sales have been very good for a small press book, but in absolute numbers that is still not a lot of books. Now that I have gotten the kind of enthusiastic feedback I have, it seems even more important to get the word out about this book. It seems there are still a lot of people who don't read the web sites and blogs and who really benefit from access to the "Dead Tree" version.
Here's a page that links to some of the excellent reviews and blog discussions that have been published online and the sites where you can buy Blood Sugar 101:
Blood Sugar 101, The Book.
Just last week I got a letter from my hero, Dr. Richard K. Bernstein. I'd sent him a copy at the suggestion of Steve Freed of Diabetes in Control after he published a very positive review of the book. But I didn't expect to hear back from Dr. Bernstein since I take a very different approach to diet than he does and because I knew he was still enthusiastic about TZD drugs which I write are dangerous for people with diabetes.
So imagine my surprise when I opened his letter and read that the enjoyed Blood Sugar 101 and believed it contained information available nowhere else and that people with diabetes should read it! I've written to ask him if I can quote what he wrote and until I hear from him, I won't cite his exact words, but you better believe I was walking on air for a few days after I got that letter!
The challenge with marketing this kind of book is that because I'm not a doctor and because the book is published by a small press, I can't go on the radio or TV to promote it, and the book chains won't stock it on their shelves. So that means I pretty much have to rely on whatever word of mouth recommendations I can stimulate to get people to buy it from the online bookstores where it is available.
So that leads to this blatant plea for your help. If you have read Blood Sugar 101 and have found it helpful, let people know. Also, ask your local public library to stock it. It is available from Baker & Taylor, the company that sells to libraries, and most libraries will order books that patrons ask for.
If you have any other ideas for how we can get more people reading this book, let me know. Sales have been very good for a small press book, but in absolute numbers that is still not a lot of books. Now that I have gotten the kind of enthusiastic feedback I have, it seems even more important to get the word out about this book. It seems there are still a lot of people who don't read the web sites and blogs and who really benefit from access to the "Dead Tree" version.
Here's a page that links to some of the excellent reviews and blog discussions that have been published online and the sites where you can buy Blood Sugar 101:
Blood Sugar 101, The Book.
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