The Diabetic Pharmacist Blog

Do You Know The Signs of DKA (Diabetic Ketoacidosis)?

By Brian Ray on Wednesday, December 21st, 2011 | No Comments

Do You Know The Signs Of DKA?

Every Type 1 diabetic should know what DKA is, it’s symptoms and how serious it can be. It might save you a trip to the hospital.
DKA (Diabetic Ketoacidosis) is usually caused by an interruption in your insulin regimen (missing injections or an improper working insulin pump) or a severe illness like flu, heart attack, or stroke.
In DKA, ketones build up in the blood stream. Ketone production is controlled and limited by insulin, and if you stop taking your insulin, more ketones are produced. If you have an illness, the body produces stress hormones which counteract insulin action, thereby also causing an increase in ketones. Your blood glucose levels increase, leading to increased urination and dehydration, which itself causes higher glucose levels and more ketones, like a vicious circle.
The symptoms of DKA are nausea, vomiting, abdominal pain, dry mouth, thirst, and excessive urination. In advanced stages, deep breathing patterns develop. This brings on the telltale sign of DKA, which is a fruity odor to your breath. If your level of consciousness is decreased, a prompt trip to the hospital is in order.
Some people incorrectly think that if they are sick and not eating, they don’t need to take their insulin. This results in rapid development of DKA. It is important to ask your doctor early in an illness the best way to avoid interrupting your insulin regimen. Dehydration due to vomiting, and the inability to eat and drink can cause high glucose levels and more ketones.
The best way to prevent DKA is to check your urine ketones when your glucose levels are consistently above 250mg/dl, and not responding to additional insulin shots. Urine ketone test kits are available in most pharmacies. Brand name Ketostix tests urine ketones, and brand name Keto-Diastix tests both for ketones and glucose. Be sure to keep these on hand if you are a Type 1 diabetic. It is a cheap alternative to a trip to the emergency room. It also could save your life, as DKA can be deadly.
(Diabetes Forecast Nov. 2009)

Using Metformin and Insulin Together

By Brian Ray on Tuesday, September 6th, 2011 | No Comments

The Benefits of Metformin

In past years, several short studies have found that adding metformin to the treatment plan of Type 2 diabetics who are already on insulin improved diabetes control, reduced the amount of insulin needed, and reduced weight gain. However, no long term studies had been done.
In March 2009, results of a 4.3 year study were published showing the long term benefits included weight loss and alleviating some diabetes complications, as well as blood glucose control. HbA1c was 0.4 percent lower, before and after meal glucose levels were lower, total insulin dose was decreased by 19.63 units, their BMI (body mass index) was 1.09 units lower, and their waist-to-hip ratio was lower. There was no significant lowering of CVD related measures (blood pressure, cholesterol, triglycerides).
Over time, blood glucose control declined in those patients taking insulin alone and those taking both insulin and metformin. This may just be a reflection of the progressive nature of diabetes. Along with other results, this may show that metformin may slow the progression, but not stop it.
The results of this study showed that for patients with Type 2 diabetes that are on insulin, taking metformin has many benefits that could lead to a longer and healthier life.
(Diabetes Self-Management Sept/Oct 2009)

What is the Glycemic Index?

By Brian Ray on Wednesday, June 1st, 2011 | No Comments

THE GLYCEMIC INDEX

Not all carbohydrates raise blood glucose equally. Brown rice may make your levels spike, while milk chocolate containing the same number of carbohydrates may raise it much less. This can be explained by the glycemic index (GI), which ranks foods based on how much they may raise glucose levels. And some people, whether they follow a lower- or higher-carb diet, pay attention to their foods’ GI, too. So, should you?
Here’s one thing experts in both the lower- and higher-carb diet camps agree on: The answer is no.

As you can see from the example above, low-GI foods aren’t always the smartest choice. (Hint: Brown rice is more nutritious than chocolate.) Many healthy foods actually have what the diet calls a medium or high GI. But that doesn’t mean you should swear off fruits and grains.

According to low-carb proponent Richard Bernstein, MD, FACE, FACN, too many factors affect a food’s GI to make the diet worthwhile. Take, for instance, an apple. Its glycemic index differs based on variety, how long it remained on the tree, how long it sat in the bin in the orchard and again in the store, and so on. Trying to calculate GI based on those details is nearly impossible.

William Yancy, Jr., MD, MHS, a researcher at the Center for Health Services Research in Primary Care at Durham (N.C.) VA Medical Center and associate professor of medicine at Duke University Medical Center, conducted a study that compared a low-carb diet and a low-GI diet. He found that the low-carb way of eating better improved blood glucose control.
“When low-GI diets are compared to high-GI diets, some short-term studies showed benefit and some did not. However, two one-year studies reported no benefit in A1C from the low-GI diets in the end,” says Marion J. Franz, MS, RD, CDE, a dietitian in Minneapolis. One study of people with type 2 diabetes found virtually no distinction between a low-GI and high-GI diet when it came to weight loss and glucose control.

The New Science Of “Epigenetics”

By Brian Ray on Saturday, May 21st, 2011 | No Comments

EPIGENETICS

Explanations of how diabetes develops and progresses often involves two things: genes and environment. In other words, you may be born with a genetic disposition to diabetes that is then triggered by an environmental event or behavior. As it turns out, though, these factors aren’t always so separate. Scientists are finding that the environment can affect and even permanently modify genes themselves. How and why this happens is the subject of an emerging field of research called epigenetics. And the evidence suggests that diabetes may both cause epigenetic changes and be caused by them. It’s a classic of what came first, the chicken or the egg.

The prefix epi- means “on top of” or “in addition to”; epigenetics is the modification of the surface and message of a gene without altering the underlying DNA sequence. It’s something like making a proofreading mark on a document.

For people with diabetes, high or low blood glucose may trigger epigenetic changes. Some research suggests that these changes to genes may spur the development of diabetic complications, such as kidney damage and heart disease. Even a brief exposure to high blood glucose may cause an epigenetic change that stays in your body. This is called hyperglycemic memory, and it may explain why some people with diabetes get complications in spite of having good blood glucose control on average.

The development of both type 1 and type 2 diabetes is known to be influenced by the environment. Researchers are looking into what types of environmental factors, from nutrients and toxins to behavior and lifestyle, can trigger these epigenetic changes that raise or lower diabetes risk.

Scientists suspect that a mother’s nutrition while pregnant or a child’s diet during early life may even cause epigenetic changes that persist into adulthood. For the diabetes population, this is important because the pancreas’s insulin-producing beta cells replicate very early in life and then stop. “So a cell with epigenetic changes [from early life] just stays there.” And if epigenetic changes are transferred between cells through replication, then these changes in early life may have an even greater effect since they will be passed from the mother cell to the daughter cell throughout growth.

Epigenetics is a young field and a challenging one. Just identifying epigenetic changes to genes is difficult, a bit like trying to find a single out-of-place word in a long novel. Even so, researchers may someday discover through the study of epigenetics that the key to diabetes resides at the intersection of where genes and the environment meet.

Are Carbs The Enemy?

By Brian Ray on Wednesday, May 18th, 2011 | No Comments

ARE CARBS THE ENEMY?

When it comes to diabetes, there may be no topic more fraught with controversy than carbohydrates. Sure, everyone agrees that the body uses carbs for energy in the form of glucose. But how much carbohydrate should people with diabetes really eat?
That question has divided researchers, doctors, dietitians—and people with diabetes themselves. Some insulin users in particular find that their blood glucose is far easier to control when they limit the carbs in their diet. Others think people with diabetes deserve to eat (and enjoy) the same healthy diet recommended for all Americans. All are deeply passionate on the subject. And, in a sense, they may all be right.

Today, most people with diabetes are encouraged to eat a balanced diet of lean meats and dairy, whole grains, healthy fats, and fruits and vegetables. This concept is backed by the American Diabetes Association (ADA) as well as the American Heart Association and American Dietetic Association, and it incorporates recommendations from agencies like the Department of Agriculture and the Department of Health and Human Services. While the ADA does not specify exact grams or percentages of calories from carbohydrate, the approach is generally moderate in carbs. According to Marion J. Franz, MS, RD, CDE, a registered dietitian and nutrition/health consultant in Minneapolis, studies have shown that people with diabetes generally get about 40 to 45 percent of their calories from carbs.

The moderate-carb approach stresses that grains should come in the form of whole grains instead of refined grains (like white flour), which have been stripped of important vitamins and minerals. Research has shown that eating a moderate-carb, high-fiber diet (like one that includes whole grains) may improve post-meal glucose levels and lower the risk for cardiovascular disease.

Indeed, a lot of those newly diagnosed with diabetes are happy to find out that they can still have most of their favorite foods, in moderation—as long as they lower their blood glucose with medication and exercise. (People who control their diabetes without medication or who take oral drugs will need to watch how carbs affect their glucose levels and then work with their doctor to determine the right number of carbs and amount of medication needed to stay in good glucose control.) Gone are the days of “diabetic diets” that were meager and confining. Today, the idea is that people with diabetes can eat everything recommended to those without the disease. “If we look at what’s important for all of us,” says Franz, “it’s important to eat healthy foods in the right portion sizes.”

People with diabetes looking for a one-size-fits-all “right” way to eat are going to come up short. There probably is no one way to eat that works for everyone. For some, all but nixing carbs is the ideal way to normalize blood glucose levels. For others, eating a higher-carb diet and covering the carbs with insulin or oral medications wins. This is all part of the reason that the American Diabetes Association stresses that meal plans should be geared to fit each person’s individual lifestyle.

So what should you do if you have diabetes and you’re trying to eat healthfully? First of all, keep in mind that what works for someone else may not necessarily work for you—and vice versa. You may need to experiment a bit to see how different methods affect your blood glucose levels. Consider making an appointment with a registered dietitian, who can review your individual needs and circumstances and help you tailor a nutrition plan that’s right for you. In the end, the best diet is the healthy one you’re able to follow.

2011 Diabetes Figures

By Brian Ray on Tuesday, April 19th, 2011 | No Comments

As of January 2011, CDC figures show nearly 26 million Americans have diabetes and 79 million who have pre-diabetes. Among adults over 20 years old, 11.3% have diabetes and 35% have pre-diabetes. And of those people that do have diabetes, 27% are not even diagnosed yet. Kind of scary, don’t you think?

Are You Still Taking Avandia?

By Brian Ray on Monday, March 21st, 2011 | No Comments

If you are still taking Avandia, I want to let you know about the new FDA regulations that will be starting in the very near future.

The FDA wants to restrict the use of any medications containing rosiglitazone (Avandia,Avandamet, and Avandaryl).
They will be allowed only in patients that cannot control their Type 2 diabetes with other medications. These restrictions come as a result of the increased risk of cardiovascular events, such as heart attack and strokes in people taking Avandia.
The FDA will allow it to stay on the market as long as all the following happen:

1. All patients are given complete risk information and it is documented in their medical records.
2. Consultation with your health care provider and documentation that you will not take Actos(pioglitazone) while taking Avandia.
3. Documentation from health care providers that all patients have received the risk information.
4. Physicians,patients, and pharmacists must enroll in the REMS (Risk Evaluation and Mitigation Strategy) program.

Approximately 600,000 patients are affected by this decision by the July 2010 Advisory Committee. The label changes and the REMS will take several months to complete. So don’t be surprised when your doctor starts talking to you about this new REMS program or possibly switching you to another medication (Actos).

Brian Ray, The Diabetic Pharmacist

(Drug Topics October 2010)

Believe It Or Not

By Brian Ray on Monday, March 14th, 2011 | No Comments

Here are some quick facts:

1. In 2009, the diabetic medication metformin was the 6th most prescribed medication in the US.
2. The average American consumes more than 4500 calories and 220 grams of fat during a traditional Thanksgiving meal.
3. Every 20 seconds someone is diagnosed with diabetes.

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