You asked for it, you got it! OK, maybe it was mostly our idea... but we think you're going to like it:
Say hello to our spicy new brand of diabetes advice column we're calling Ask D'Mine. This series will be hosted by my good friend, veteran type 1, diabetes author and community educator Wil Dubois — with occasional input from Allison and myself.
"Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com"
This is a place to send all your quirky or potentially embarrassing questions, behind-the-scenes curiosities, lifestyle queries, or even ethical dilemmas related to life with diabetes. In short: Don't know who else to ask? Ask D'Mine!
We're starting this first edition with our DISCLAIMER (look for it at the end of upcoming editions):
This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.
So here goes:
Becky from Minnesota, type 1, asks: This last winter storm really freaked me out (not to mention the disaster in Japan!) I was snowed in for the better part of a week. I was fine, but what if I had run out of insulin? My insurance company won't let me refill any of my medications until I'm nearly out. Does Ask D'Mine have any suggestions?
Wil @Ask D'Mine answers: There oughta be a law... but there isn't. Insurance companies have been getting more and more iron-fisted when it comes to refills, and generally speaking you can't refill until you are down to five days of meds. So my first thought is that if you ordered refills like clockwork every 25 days, you might be able to add a five-day cushion each month, which would give you 60 days of emergency meds by the end of the year. Sound too good (and too simple) to be true? I called a bunch of pharmacists and found out that most insurance companies generally peg refills to calendar dates based on the original prescription date, so you can't effectively just "pick up" an extra couple of days each month. *sigh* Those #&$% insurance folks are always one step ahead of us.
This means your doctor is your best bet, and has at least two aces up his or her white sleeves: The first ace is samples. Depending on what meds you're on, and which drug reps have dropped by lately, it might be possible to score a few extra vials or pens of insulin from your doc just by asking. If you are able to do this, be sure to "rotate your stock." In other words, don't just set the sample a side for a rainy.... errrr... snowy day and let it go bad. Use the sample right away, and set aside the prescription from the pharmacy. The next month, set aside the new prescription and use the one you set aside the month before, and so forth. Comprendo?
The second ace up those white sleeves is an Rx pad. Ask your doc for an emergency prescription. It's well within your doctor's power to write you a 'script for a month's supply above and beyond the usual. The only problem with this approach is that when you go to get this filled, your insurance company will likely fight it on the basis that they've already paid for your requisite meds for the month. There'll be some back and forth and your doc's nurse will need to do some paperwork called a "prior authorization," so buy her flowers or candy as appropriate for her trouble.
Then just sit back and let it snow, let it snow, let it snow.
Michelle from Texas, type 1, writes: My boss's husband was diagnosed with diabetes last week. He's overweight, in his early 40s, and has two relatives with diabetes. His fasting was 323 and A1C is 14. He was put on two orals (Metformin and another one my boss can't remember the name of).
I told her I'm surprised his doctor didn't put him on insulin to at least get his numbers down faster. I gave her a meter, but he hasn't been testing because the doctor told him to wait until he went to the education class. I told her that's a load of shit and that he should be testing at least after every meal. They're calling around for an appointment with an endo. So with that tiny bit of information, is an orals-only treatment plan called for?
Wil @Ask D'Mine answers: Thanks for writing! Well, there is a lot of ground to cover here so let me dive right in. Middle-aged, overweight, and swimming in a gene pool full of diabetes is the classic recipe for type 2 diabetes. That, coupled with the fact your boss's hubby didn't go into a coma with that wicked high A1C, is pretty good evidence that he's been diagnosed T2.
The reason that matters is that oral meds are commonly used as first-line therapy for treating T2, so I wouldn't assume his doc is a complete idiot for going that route.
However, most pills for diabetes will buy you about a 1% drop in A1C. That means putting the poor guy on two pills could be expected to drop his A1C from 14 to 12; so we still need to make him a reservation at the dialysis center. Of course there is more to the story than just pills. If the dude has been drinking soda and noshing candy bars, even some modest diet changes could lower his blood sugar much more than any pill could hope to.
So, as to an insulin start.... well...
OK, here's the deal. Getting someone down "faster" doesn't necessarily mean better. Remember that the risk of a high-BG coma (called DKA) is remote for T2s and the tissue damage from high blood sugar is gradual, while on the other side of the coin quickly changing the blood sugar environment can stress the heart. Slow and steady is a legitimate way to win the T2 race.
Also, insulin can be tricky to teach, dangerous to use, and can have a heck of a negative impact on a patient's mental state, as we all know. If the doc believes he can get this man's diabetes in control within six months without insulin, then it probably is a bad idea to push insulin right away.
As to the issue of not testing, it may surprise you that I'm not sure this is a load of shit at all. The missing piece of the puzzle is the med your boss can't remember the name of. Look, our new T2's BG is currently high as a kite. Testing out of the gate will only confirm this. Test after test. Day after day. Frankly, testing is going to depress the shit out of him, and that's not a great way to start out your diabetes career. The only reason for him to test right now is if the mystery pill carries a risk of low blood sugar. There's a medicine chest full of oral drugs out there for diabetes. A few of them carry the risk of low blood sugar, but many do not.
On top of that, there's probably very little to learn by having him test after meals at this point. We know his fasting BG is a whopping 323. Well, at least one time it was. We can't say for sure if that's typical. With an A1C at 14, his average blood sugar for the last three months is 355 mg/dL, which to me suggests he's very high but somewhat stable. If he were shooting up even more after meals, I'd expect a greater difference between the fasting sugar and the average sugar.
As to the endo, frankly, endo's are part of the type 1 playbook. Most T2s don't have one and don't benefit from having one. On the surface, going off the details we have, it sounds like the doc did OK. He went straight to two oral agents and got the guy signed up for education. The doc probably also told him to give up smoking, avoid stress, and eat nothing but tofu and cottage cheese. But it really didn't matter what the doc said, because everything thing that follows that initial "Mr. Jones, you have diabetes" just disappears into a fog for the patient, anyway.
Medication on board. Education in the pipeline. Instructions to the patient not to test until he can understand how to test and what the numbers mean. Check!
My verdict: rather than a load of shit, probably a good start.