Diabetes Bites is published (nearly) monthly by Integrated Diabetes Services LLC and is distributed to more than 5000 individuals who either have or treat diabetes. For editorial comments, please contact email@example.com. For advertising opportunities, please contact firstname.lastname@example.org or call (877) 735-3648.
Integrated Diabetes Services provides diabetes management consulting in-person or remotely via phone and the internet. Please visit www.integrateddiabetes.com for details.
Gary Scheiner MS, CDE – Owner/Clinical Director
Lisa Foster-McNulty, MSN, RN, CDE – Director of Patient Care and EducationJennifer Smith, RD, LD, CDE – Director of Lifestyle and Nutrition
Debbie Liebman, BSN, RN – Office AdministratorKaren Bellopede – Client Service CoordinatorDebbie Conley – Accounts Receivable
333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096
(610) 642-6055 Toll-free: (877) 735-3648
Facebook: Integrated Diabetes Services
Type-1 University is the web-based school of higher learning for insulin users. There are live and pre-recorded courses on a variety of topics.
Cover Story: Will You Be Our Winner?
Logo Contest! We're looking for a new logo for our "Diabetes Bites" newsletter. The current logo shows a creature taking a chomp out of a glucose meter displaying a highish reading (view past issues at www.integrateddiabetes.com/news_dbites.shtml). We're open to just about anything, keeping in mind that we like a sense of humor but still want a professional look. And this should go without saying, but keep it appropriate for all ages!
Finalists will be selected by our panel of hypoglycemic experts, and presented in the next issue of Diabetes Bites for reader voting. The winner will be the focus of a feature story in the following issue.
Send your designs (preferably in pdf format) to: email@example.com
Glucagon…that scary red box that strikes fear into the hearts of caregivers and those who live with type 1 diabetes. We have glucagon at home. We have one at school. We take it on vacation. As a mom to a teenage son with diabetes, I have dutifully filled his glucagon prescription for the past 11 years and have practiced using it on a piece of fruit each year as it expired. But I have never actually used it on my son. Not until this spring, that is.
On our second day in Costa Rica, my son ate a seemingly safe food choice: a cooked flatbread pizza. The cheese was tainted with a toxin and within an hour he was experiencing signs of food poisoning. What this means for the diabetic is that his body immediately knew it would reject the food, and so it did not use the 12 units of insulin that my son had delivered to metabolize the carbs. Our first sign that something was wrong was a dangerously low blood sugar of 37. When his blood sugar would only go up to 60 after drinking 16 ounces of Coke, and nausea had by this time set in, I knew we had to act quickly. I sent my husband and older son tearing down the beach to fetch the glucagon, which was back in our hotel room. It would be a 25 minute round trip sprint before my son returned with the glucagon; 45 minutes before my husband could get back with the car.
Shortly after they left, the projectile vomiting began and with it, the drop in my son’s blood sugars resumed. It was the longest 25 minutes of my life waiting for that shot of rescue glucose, not sure if my son would have a seizure, or worse. With trembling hands and without any daylight left I gave him a life-saving dose of glucagon. I was so thankful I had practiced using glucagon every year; in an emergency, it is very difficult to stay calm and read directions! Even still, I was unable to get all the glucagon out in the one large needle, so I gave the rest using his insulin syringes.
We made it back to the hotel and a doctor came about an hour later to hook my son up to an IV. By this point he had large ketones and was in desperate need of fluids and dextrose, so I could give him some insulin and flush out the ketones. The next day he was rushed by ambulance 4 hours south to a private hospital in the capital, San Jose, where he spent the next 3 days recuperating. It was a modern hospital where he received wonderful care, and so I asked for two things: another glucagon (in case he got food poisoning again; it’s not a virus, he wouldn’t have built up any resistance to it so it could happen again at any time), and ketone strips (we blew through a 50-pack in 3 days). Glucagon: no can do. It’s too expensive to keep so they haven’t had glucagon in Costa Rica for over 10 years. Ketone strips: it was VERY difficult to get them and when we did, they were enormous strips that tested everything from ketones to pregnancy, it seemed!
So here are my takeaways:
1. Always have glucagon READILY available. Taking it on vacation but not taking it on your day trip that is 1-hour away from your hotel will do you no good!
2. If you use your one glucagon, you will want to have another on hand. If the doctor hadn’t been able to come when he did, I may have needed to use a second glucagon just to raise the blood sugar enough to give some insulin.
3. If you get sick, one bottle of ketone strips may not be enough. Pack a second bottle.
Starting in August, our top-notch Director of Lifestyle and Nutrtion services, Jenny Smith, will be working with us full-time. In addition to being a Registered Dietitian and Certified Diabetes Educator, Jenny has type-1 diabetes herself and recently had her first baby. A type-1 athlete in her own right, Jenny is one of the leaders of Team Wild, a volunteer organization that educates and inspires people with diabetes to tackle a variety of challenging athletic endeavors.
Please contact our office (877-735-3648 within the U.S., +1-610-642-6055 outside the U.S.) to schedule an appointment with Jenny via phone or video chat. She is available to assist with:
- Weight control
- Meal planning
- Training for athletic events
- Specialized diets (including gluten-free)
- Insulin pump fine-tuning
- Advanced carb counting skills
- Pregnancy planning/management
…and much more!
* Philly for “you all”
Calling All Medtronic Pump Users!
Medtronic has sent out an Urgent Device Safety Notification that all Medtronic pump users should be aware of. It appears that any liquid (including insulin) that is on top of the reservoir at the time the tubing is connected can cause blockage of air vents in the tubing connector, which can alter insulin delivery. Bottom line: Make absolutely sure there is no insulin on top of the reservoir when connecting the tubing. Best way to avoid the problem is this: After filling a reservoir, make sure the reservoir is on TOP when pulling it out of the blue "transfer" piece. Do not wipe the top of the reservoir with anything (including alcohol) after filling it with insulin. If you notice liquid at the top of the reservoir, discard it and start fresh. Leaks in reservoirs can cause under-delivery of insulin and failure to trigger "no delivery" alarms in the event of a blockage.
There is a list of lot numbers which are part of this recall; check your supplies. Both 180 and 300 unit reservoirs are part of the recall. These reservoirs were distributed between October 2012 and January 2013. Details can be found at http://www.medtronicdiabetes.com/support/product-updates
In other Medtronic news, the company has decided to discontinue Sof-set and Polyfin infusion sets. IDS has some stock of Sof-set infusion sets that have been donated to us, in case anyone would like them. Please contact us at firstname.lastname@example.org if you are interested. Pump users currently using either Sof-set or Polyfin infusion sets will receive a letter to inform them of this discontinuation.
See the Medtronic website at www.medtronicdiabetes.com/support/infusion-set-support/compare-set for an overview of the alternate infusion sets available. Affected users should discuss the most appropriate alternate infusion set with their healthcare team. We at IDS would be happy to help.
Here is what to expect: at the time of the next order, Polyfin users will receive their normal order amount; Sof-set users will receive one box of Sof-sets. At that time, each patient will also receive a box of the selected alternate set (and an inserter if needed) free of charge.
Questions can be directed to Medtronic at email@example.com
And For the OmniPod Crowd…
Trying to be more green? Insulet has bags that can be used to return up to 50 pods by FedExing (if that wasn’t a word before, it is now!) them back to Insulet. Call Customer Care at 1-800-463-3339 to get the recycling kit.
One more tidbit—if you fill one of the new pods with more than 200 units of insulin, you may get an occlusion or pod error alarm. It’s an easy mistake to make, because the syringe for filling a pod will hold 215 units, which is enough to trigger this problem. Read your syringe carefully, and only fill it to the 200 unit mark (or less), so that you don’t overfill and waste a pod.
Managing insulin-treated diabetes requires more behind-the-scenes thought and planning in day to day life than meets the eye. Too bad we can’t set our brains to “defrag” as we can with a computer! For a quick read on the subject, take a look at this blog post: http://www.accu-chekdiabeteslink.com/driven-to-distraction-the-reality-of-managing-diabetes-every-day.html
There’s a New Clinical Trial in Town…
TrialNet has already discovered that people recently diagnosed with Type 1 who took Abatacept (CTLA4-Ig) continued to produce insulin for a longer period of time than those who did not receive the drug. The details of the study were published in 2011 in The Lancet, a peer-reviewed medical journal. Now Trialnet is recruiting high risk relatives of people who have Type 1 to learn whether Abatacept can prevent or delay the onset of the disease.
Even though the chances remain small, relatives of people with type 1 diabetes are 15 times more likely to develop the disease than those with no family history. TrialNet offers a screening test that can identify individuals at increased risk years before symptoms occur. Screening is available at no charge to relatives of people with type 1 diabetes at more than 200 TrialNet locations nationwide. A screening kit is also available by mail.
Give that Immune System a Good Workout—You‘ll Be Glad You Did!
There’s a relatively recent theory on Type 1 Diabetes called the Hygiene Hypothesis, and a Massachusetts-based company called Coronado Biosciences ( www.coronadobiosciences.com) is basing its products upon it.
First theorized by Dr. David Strachan in the British Medical Journal in 1989, the hygiene hypothesis observed that the autoimmune conditions hay fever and eczema were less common in children from large families. Ostensibly this is because children in larger families are exposed, through their siblings, to more infectious agents.
Dr. Joel Weinstock, of Tufts University, uses the Hygiene Hypothesis to explain why the incidence of autoimmune conditions ranging from Crohn’s disease to multiple sclerosis to Type 1 diabetes is on the rise throughout the world. It is thought that the developed world has done such a great job of reducing environmental germs (think pasteurized milk, vaccines to immunize against infectious diseases, etc.) that our immune systems aren’t kept busy doing what they are supposed to do for us. So rather than keeping us from getting sick, the immune system essentially creates disease by destroying our healthy cells. Our vulnerability to autoimmune disease is purportedly passed on to our unborn children during pregnancy, possibly explaining why these diseases have become more common over the past 30 years.
So to reset the immune system, the body can be exposed to controlled doses of parasites. This spurs on the immune system, telling it to get to work killing foreign parasites. This process is not unlike our practice of using immunizations to prevent communicable diseases such as Smallpox or Polio. Enter Coronado, which is developing a therapy designed to retrain the immune system. The Trichuris suis ova, or TSO, is more commonly called the pig whipworm. Harvested from pig stools, it is sanitized and then distilled into a saline solution that can be consumed orally. TSO never enters the human bloodstream, and it cannot multiply in humans. In a matter of weeks, it is digested and eliminated from the body, making it a promising therapy.
In saline solution, pig whipworm eggs are both odorless and tasteless. Too small to be seen by the naked eye, the Trichuris suis ova cannot survive in humans longer than two weeks.
The worms appear to impact the immune system in three major ways. They cause changes that activate regulatory T-cells, which reduce the immune response, and they seem to prevent activation of “effector” T-cells that, if left unchecked, will destroy the healthy cells they see as foreign. They also seem to reestablish the normal microbiome in the stomach which helps to maintain intestinal health. With the permission of both the FDA and European Medicines Agency, Coronado is studying TSO as a potential treatment for various autoimmune conditions.
So far, early trials have shown positive responses in patients with Crohn’s disease, ulcerative colitis and multiple sclerosis. The next phase of trials will continue to test TSO therapy on these diseases, as well as psoriasis and autism. Trials in subjects either recently diagnosed with Type 1 diabetes or at risk for developing Type 1 should begin later this year in two U.S. locations and one overseas.
Blood tests showing the presence of specific auto-antibodies can reliably identify people who are at risk for developing Type 1 Diabetes. Screening is focused on children and adolescents whose parents or siblings have the disease, and is being done right now under the guidance of TrialNet ( www.diabetestrialnet.org). Presence of only one auto-antibody does not guarantee that one will eventually develop Type 1, but there are mathematical formulas for assessing risk since there are more auto-antibodies in the serum as blood sugar starts to increase. The way Coronado and other companies are planning to measure the effect of any therapy, including TSO, is to monitor the subjects over a long period, while also identifying surrogate markers. This may help to fast-track regulatory approval.
The effects of TSO therapy in those recently diagnosed with Type 1 will be relatively easy to measure. Many people with Type 1 diabetes go through a “honeymoon period,” where beta cells that have survived the first onslaught of the immune system’s attack continue to produce insulin. Introducing a TSO therapy might prolong the honeymoon. Continuing to produce some endogenous insulin would be the desired outcome, as it could potentially delay full dependence on exogenous insulin for years. Hopefully this would prevent some of the end-stage complications often associated with years of living with diabetes.
Kudos to Betty Jackson
This is Gary with Betty Jackson, who was one of his "original" clients when he started the practice (they're clinking their pumps, like champagne glasses). Betty recently received the 50-Year Gold Award from Joslin Diabetes Center for surviving more than 50 years with Type 1 Diabetes. We're incredibly proud of her! What's even better is that she continues to take exemplary care of herself. Despite limited vision and physical challenges, Betty manages to stay active and keep her blood sugars within a consistently tight range (with a little bit of coaching and "tweaking" from our staff from time to time). Great job, Betty!
If you have Type 1 Diabetes, your body lacks something that everyone else has. Insulin, Amylin…tell me something I don’t already know! Well, here’s a new twist on an old story: SOGA, a protein that lowers blood glucose, is missing in type 1 patients.
SOGA is released along with insulin and works when food is being consumed by blocking the production of a storage form of glucose called glycogen. The protein begins to work when you eat, so excess glucose is not produced. Without diabetes, SOGA tells the liver that it doesn’t need to make glucose. This process does not happen in people who have diabetes. In the presence of diabetes, glucose after meals comes from both the food and the liver.
In both Type 1 and 2 patients, the body produces more glucose than it actually needs. The drug developer is working on a solution that will halt the body’s production of glucose. The new drug would stimulate the SOGA production so that glucose production is diminished, thereby lowering blood glucose levels.
Researchers are now working on a drug that would stop the production of the body's own glucose. Since SOGA can't be ingested, the drug would be a formulation designed to stimulate the body's own SOGA production. In studies of mice with blood sugar values of 400 mg/dL, SOGA was raised and their blood sugar levels came down to normal levels within 4 days. When a pill that increased SOGA was given to mice without diabetes, nothing happened, leading the investigators to believe that SOGA could effectively lower blood sugar without causing hypoglycemia. Perhaps in some people, SOGA might eliminate the need for insulin entirely.
Be a Good Girl/BoyScout and Be Prepared!
The thing about emergencies is, well, you don’t know about them ahead of time. Laura M. Laria and Judith Jones Ambrosini have developed a checklist for those who are interested in being ready at a moment’s notice. They call it WAD—The Well Armed Diabetic. Their checklist includes suggestions for medical supplies, non-perishable food items, and personal incidentals.
Laura and Judith write, "The following survival necessities and supplies are an emergency comfort zone every person with diabetes, chronic illness, and disabilities should consider organizing for themselves ahead of time to have on hand in case of danger, crises, fire, evacuation or natural disaster. Insulated bags and backpacks are available at most stores. Find one in a bright color or with reflective strips that are easy to identify, attach a laminated name tag on it, fill with the following compendium of items to insure care of basic diabetes, chronic illness, and disability needs for 2 weeks. Hang it in a familiar spot that is easy to access when evacuating."
For the detailed checklist, they can be contacted at firstname.lastname@example.org
Beat the Heat
"It’s not the heat; it’s the humidity." Don’t you just want to smack the next person who says that to you? Currently it is hotter in Pennsylvania than it is in Florida. Go figure! If you are looking for a meter that can take these temperatures, look no further. This identifies the maximum temperature that each "heat-tolerant" meter will tolerate. They are listed as degrees Farenheit/degrees Celcius.
- Precision Xtra: 122/50
- ReliOn Ultima: 122/50
- Breeze2: 113/45
- Contour Next EZ: 113/45
- Contour Next Link: 113/45
- Contour TS: 113/45
- Contour USB: 113/45
ADA: SGLT2 Inhibitor Works in Type 1 Diabetes as Add-on to Insulin
An investigational oral agent for Type 2 Diabetes may also work as add-on therapy in Type 1 Diabetes. At an ADA poster session, researchers reported that in a phase IIa clinical trial, patients taking dapagliflozin had better blood glucose control and needed less insulin than subjects who took placebo. Specifically, the investigational drug improved fasting blood glucose as well as after-meal values. It minimized fluctuations in glucose and allowed for dose reduction of insulin. Hypoglycemia occurred in the patients taking the investigational drug as well as in the placebo group.
The mechanism of action of dapagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, would be benefit Type 1s because it is even effective in patients who have impaired kidney function. Its blocks the reabsorption of glucose in the kidneys, spilling more glucose into the urine.
The FDA did not approve dapagliflozin in January 2012, due to concerns with breast and bladder cancer risks. However, the FDA approved another SGLT2 inhibitor, canagliflozin (Invokana), in March. Dapagliflozin drugmakers Bristol-Myers Squibb and AstraZeneca said they will re-submit their application to the FDA by the end of summer.
Side effects, particularly hypoglycemia, were similar between the patients who took the drug and those who took placebo. While the researchers reported positive urine ketones in all treatment groups, they generally weren't associated with symptoms and tended to be higher among subjects taking the larger doses of the investigational drug. It is worth noting that few patients had urinary or genital side effects , which are common with of this class of drugs.
The study was limited by its small population size, and the results will best be used for future research hypotheses.
First in Class Medication Approved for Type 2 Diabetes
Invokana (canaglifozin) is the first drug in its class of sodium-glucose co-transporter 2 (SGLT2) inhibitors. Johnson & Johnson's new drug is used to treat type 2 diabetes in conjunction with diet and exercise. Some endocrinologists are experimenting with off-label use in patients with Type 1.
Invokana works by preventing the kidneys from reabsorbing glucose and by promoting glucose excretion. This medication is effective in reducing blood glucose levels because it causes glucose to be excreted into the urine. Further information about how Invokana works is available on the drug’s web site at http://www.invokana.com/about_invokana/how_invokana_works.
Invokana has been shown to improve A1c levels and fasting glucose levels in nine clinical trials involving over 10,000 patients with Type 2 Diabetes. Another advantage shown in Phase III studies was the ability of Invokana to reduce body weight and systolic blood pressure. This medication can be taken by itself or in combination with insulin, metformin, sulfonylureas, or pioglitazone.
Invokana should not be prescribed in patients with severe kidney problems. The main side effects seen in trials were urinary tract infections and vaginal yeast infections due to the high amount of glucose in the urine. Dizziness was a common side effect. The FDA expects Johnson & Johnson to carry out post-marketing studies in the future. For more Information, see the Product of the Week. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm345848.htm
For mail-order diabetes supplies (test strips, pump supplies, sensors, prescriptions and more), we are proud to recommend Byram Healthcare. Byram works with most public and private insurance plans, provides a very wide selection of diabetes self-management products, and offers excellent customer support. Call 877-902-9726 (mention referral number 126736) or visit www.byramhealthcare.com.
Introducing the latest in glucose sensing technology
Dexcom® is excited to announce the continued innovation of the Dexcom Continuous Glucose Monitoring (CGM) system by introducing Dexcom G4™ PLATINUM. With modern design and exceptional accuracy, the Dexcom G4 PLATINUM provides enhanced user conveniences and sensor performance that customers have long associated with Dexcom. Continuing our vision of patient-centric solutions, the Dexcom G4 PLATINUM brings the first, large color CGM screen to life, along with other user-friendly features and remains the only system with a sensor approved for up to 7 days of wear. By more seamlessly integrating into people’s lives, Dexcom anticipates continued improvements in patient compliance and retention that is already the highest among CGM companies.
Demonstrated clinical benefits of CGM include:
· Improve HbA1c levels without increasing hypoglycemia3
· Ability to reduce glycemic excursions4,6
· Improve time spent in ”target levels” or euglycemia5
· Reduce frequency and time spent in hypoglycemia5
App Rap: myfitnesspal.com
It seems as though everyone has heard of myfitnesspal.com, so I had to see make sure I was in on the secret. It’s a free online diet and fitness community. The nutrition and calorie database contains over three million foods!
You can log in from your computer, or just use a phone app. It’s available for iPhone, BlackBerry, Android, and Windows phones. Research has shown time and again that tracking the foods you eat is one of the simplest and most effective ways to lose weight. Myfitnesspal makes it easy by remembering the foods you eat the most often, so you can very quickly add them to your record each day. If you are an IDS patient and share your username and password with us, we can easily review your records and give feedback.
There is a searchable exercise database, which allows you to track calories burned. Myfitnesspal also has a blog and message boards, so you can interact with like-minded others to get the support you need. Check it out atwww.myfitnesspal.com/
The Diabetes Store is Open!
Until There is a Cure, Gary Scheiner’s latest book, details all that is new and effective in diabetes treatment. 160 pgs; from Spry Publishing. Order from Integrated Diabetes Services by calling 877-735-3648 (outside US: +1-610-642-6055) or visiting the IDS webstore. $16 plus s/h.
The 2nd edtion of Think Like a Pancreas: A Practical Guide to Managing Diabetes With Insulin has sold more than 25,000 copies worldwide… and counting! This all-new edition includes detailed sections on continuous glucose monitoring, new medical options for insulin users, smart pump therapy, web-based support and management resources, and pregnancy & type-1 diabetes.
This just in: we are carrying a new book called Raising Teens with Diabetes: A Survival Guide for Parents by Moira McCarthy. Do you need a copy? We have'em in stock now!
Sample a CGM
Use of Continuous Glucose Monitors is growing steadily as the systems become more accurate & user-friendly, and insurance coverage expands. Still, many people are hesitant to purchase a system outright without knowing if it’s really worth all the effort. If you’re interested in trying a CGM (and learning some things that can improve your control), Integrated Diabetes Services offers a CGM Trial Service. This service is available just about anywhere since we can ship the necessary equipment to you and talk you through the sensor attachment process via phone or video chat (skype). Select either a two-week Dexcom Seven-Plus or G4 trial, or a one-week Medtronic sensor-augmented pump trial (you must have a Medtronic 522, 722, Revel or Veo pump). The trial service includes a detailed analysis of your sensor data as well as specific recommendations for fine-tuning your glucose control. The cost for the service is $290, including all necessary equipment, initial training and data analysis. Details can be found at http://www.integrateddiabetes.com/cg_trialserv.shtml. Call 1-877-735-3648 to schedule.
??? Trivia Question ???
During a basal test, which is permissible?
A. Low-carb snacks
B. Typical exercise
C. Rapid-acting insulin
D. Usual basal insulin
??? Answer to Trivia Question ???
Find out for yourself! To brush up on the particulars of basal testing, stop by our web site at http://www.integrateddiabetes.com/p_basaltest.shtml