Finally, With Eyes Wide Open

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This is an odd title, but an even oddermessage from an unexpected source. I guess if you believe insomething long enough it may just happen. I have been saying thatothers should be promoting insulin earlier for the treatment of type2 diabetes and not be the medication of last resort. Finally,Jonathan Marquess, PharmD, from the Institute for Wellness andEducation Inc in Atlanta, Georgia is saying it.
I do not mind that it is a pharmacistsaying this as long as this happens more frequently. He does notcriticize the American Diabetes Association (ADA) for setting the A1clevel at 7.0%, but at least he is saying, “We know that diabeticcomplications happen at a more prevalent rate when the A1c is above7. Those diabetic complications are where we're really spending big,big money in this disease state.”
I agree, but would say that we need toignore the ADA and adopt the American Association of ClinicalEndocrinologists (AACE) level of 6.5%. At least then, there would besome room for error although even this could or should be lower. Ialso appreciate this statement by him, “All too often,physicians, nurses, and pharmacists, will advise patients to takeoral agent #1, then oral agent #2, then oral agent #3, and then say,"Wow, I guess it's time to start insulin."”
He does cite some statistics that arealarming, but believable. Of the approximately 43 percent of peoplehaving A1c levels above 7% he does not make any statement about howimportant blood glucose testing should be. This I think is where hemisspoke or possibly was misquoted as these people with diabetes needto be testing more and moved over to insulin to prevent or delay thedevelopment of complications.
It is true that people with diabetesneed to be concerned with morning fasting blood glucose levels andtheir two-hour postprandial glucose levels. This should be importantwhether their A1c is above or below 7%.
When he answers the question aboutinsulins, he is correct that we have some great basal insulins andrapid-acting mealtime insulins. His answer about misconceptionsabout insulin is a little outdated and he missed a great opportunityto dispel a few more of the insulin myths. He concentrated more onfear of needles and people being afraid of the past big needle size. He did mention that people think of insulin as inconvenient and manyhave the fear of hypoglycemia. I will give him credit for attackingthe perception that going on insulin means you did something wrongand had been a bad patient. Sometimes this cannot be helped so it isnot their fault.
He did mention insulin pens, which arenot available to everyone, but are becoming more popular andavailable. These will be easier to teach and should help by reducingmedication and dosing errors. Insulin pens may also help patientsovercome dexterity problems.
Dr. Marquess did shine when talkingabout education and that it takes time. He talks about patientsneeding to watch what they eat, learn what the numbers mean in bloodglucose monitoring. He talks about physical activity and thepotential for problems of hypoglycemia and how to treat with glucosetablets. He did an excellent presentation about needing to go backand reinforce many ideas on a continuous basis and ask the patienthow they are doing.
For such a short interview, he covereda lot of material fairly well and I commend him for that. I haveheard doctors fumble and make a mess of less material. Read theinterview here.