October 28, 2006

The Earliest Complication?

I've kept my blood sugar as close to normal as possible for the last eight years, with A1cs almost always in the 5% range. As a result, my eyes and kidneys test out great and I have no neuropathy in my feet except for the nerve damage caused by my ruptured disc (which is distinguished from diabetic neuropathy in that it is only on one side, not symmetrical).

But I have developed one, to me, serious complication which my researches have found few doctors, except for the diabetes expert, Dr. Richard K. Bernstein, recognize as being a diabetic complication.

That complication is tendon damage.

Tendon damage can manifest many different ways. The most frequently detected is carpal tunnel syndrome. This recent study found that people who had been diagnosed with carpal tunnel syndrome were 36% more likely to later be diagnosed with diabetes, regardless of other diabetes risk factors.

One reason for this may be that just slightly higher than normal blood sugars cause tendons to grow abnormally thick. A study that linked tendon thickening to high blood sugars was published in Diabetes Care

Thickness of the Supraspinatus and Biceps Tendons in Diabetic Patients
Mujde Akturk, MD, Selma Karaahmetoglu, MD, Mahmut Kacar, MD and Osman Muftuoglu, MD.

Another diabetes-related form of tendon damage results in frozen shoulder. Frozen shoulder is known to be common among people with diabetes, though it occurs in people who have not been diagnosed with diabetes, too. My guess is that careful examination of post-prandial blood sugars in "non-diabetic" people with frozen shoulders not originating from sports injuries or other known traumatic events might show that the "non-diabetic" people with frozen shoulders have significantly elevated postprandial blood sugars.

Dr. Bernstein describes "piriformis syndrome" as another diabetic-related tendon problem in his article Some Long-Term Sequelae of Poorly Controlled Diabetes that are Frequently Undiagnosed, Misdiagnosed or Mistreated

I myself have yet another constellation of tendon problems that manifests in my feet. It is called "tarsal tunnel syndrome" and is the foot equivalent of carpal tunnel, resulting in painful shooting pains, first when walking up stairs, and later when it worsens, just plain walking.

Why are tendon problems often the Sentinel Complication--the first warning that something is seriously amiss? Because tendons in their normal state don't have much of a blood supply, so anything that compromises the blood supply to muscles, even slightly, will deprive the tendons of the nutrients they need to keep healthy. This mild failure of circulation starts happening even at the "mildly impaired" blood sugar levels most doctors dismiss as "pre-diabetic" and, all too often, ignore. Hence a failing tendon can be the first sign of microvascular problems.

MRIs show that it is possible to have tears in your tendons without any pain or other symptoms. You can read more about one kind of tear related to frozen shoulder HERE.

But if you are unlucky, as I have been, the tears will be in places that impinge on nerves and the pain can limit your mobility (a medical euphemism that translates into "making everything you do hurt like hell so that you mostly want to stay home, curled up in a fetal ball.")

Dr. Bernstein makes the point that just lowering blood sugars will not reverse these tendon problems which take a while to heal, and may respond to time and trigger point therapy, though he suggests normalizing blood sugars may stop new ones from starting.

My own experience has been that my tendon problems have gotten significantly worse after I have made major efforts to lower my blood sugars. My first frozen shoulder occurred after I dropped my A1c to 5.2% from the mid 6% range after diagnosis. Since starting insulin and bringing my fasting blood sugar down to truly normal (for the first time in my life) I've had tendon problems in my foot, my knee, and most painfully, my shoulder ,which is acting like it has a seriously torn rotator cuff.

Why this should be is a mystery, but since other complications initially get worse--or more painful--with improvement of blood sugars, like neuropathy and retinopathy, it is possible that there is some reasonable explanation.

If you've had problems with tendons, I'd love to hear from you about how they resolved and whether better blood sugar control made them better or worse.

October 23, 2006

New Pages on "What They Don't Tell You About Diabetes"

I created new "Complications" section on What They Don't Tell You About Diabetes. I'll be adding more pages and revising these new pages as time goes on.

The most important information is probably on the "retinopathy" page where I link to a good review of what is known about the worsening of diabetic retinopathy with improved control. The short version is that it happens, especially with people taking insulin, but long-term even if you experience temporary worsening as you get better control, over time you'll end up in MUCH better shape. And gradually improving blood sugar, rather than doing it fast doesn't appear to prevent the short-term retinopathy worsening that occasionally occurs.

I've also started a FAQ page which you can find limked from the main page of the site. I respond there to some of the common questions visitors write to me.

October 18, 2006


UPDATE (April 2, 2013): Before you take Byetta, Victoza, Onglyza, or Januvia please read about the new research that shows that they, and probably all incretin drugs, cause severely abnormal cell growth in the pancreas and precancerous tumors. You'll find that information HERE.

Januvia UPDATE -- POSTED NOV 15, 2006

A study linked from todays Diabetes in Control Newsletter reports that the DPP-4 drugs (including Januvia) slightly improve fasting blood sugar but have NO EFFECT on post-meal blood sugars. Since it is the post-meal blood sugars that destroy your organs, this looks to me like another reason to save your pennies and spend them on something that actually can lower your post-prandial blood sugars. That might be Byetta for some of you. For the rest of us, it probably is post-prandial insulin.


Januvia is a new DPP-4 enzyme drug which inhibits the destruction of the incretin hormone GLP-1, the hormone another drug, Byetta, imitates. It has just been released with great fanfare.

Reviewing the study data that the manufacturer supplies with the press releases makes it clear that it produces very little improvement in blood sugar, despite its cost of almost $5 a day.

In people whose A1c was 8%, Januvia decreased the A1c by a measly .6%--bringing it to a level significantly higher than even the dangerously high 7% recommended by the ADA. Added to Metformin or Avandia, it got only about half of patients near 7%.

This is simply not good enough to justify the $150/month price tag. Especially when Byetta does a better job.

Unfortunately, because Januvia is a pill, doctors are going to be much more likely to prescribe it to patients than they are Byetta, even though it is far less effective in lowering blood sugar.

The real problem here is that current FDA practice requires drug manufacturers to do studies that compare their drug to placebo, NOT to other currently approved effective treatments. So while Januvia is better than placebo (i.e. nothing) it isn't better than insulin + Metformin or insulin + avandamet, which are both much cheaper than this new drug. Nor is it better than Byetta which is more expensive but more efficacious.

The drug is also being promoted as being weight-neutral (i.e. not causing weight gain) based on two studies, one of which showed a slight gain of weight in those taking the drug. This contrasts poorly with Byetta which, when it works, causes weight loss.

Finally, the manufacturer's information suggests that Januvia may be hard on the kidneys. Since most type 2s at diagnosis already have some decrease of kidney function (as shown on the microalbumin test) the wisdom of taking a drug that may be hard on the kidneys is tough to defend.

For the time being, it looks like Byetta would be a much better choice for an incretin hormone-based treatment because based on a lot of user reports when it works, it really works.

Getting Personal

After 3 1/2 weeks on the new metformin I'm back to experiencing the Reactive Hypoglycemia I last experienced in my 30s! I took my R insulin along with me on vacation and indulged in quite a lot of starchy and sugary food. At 90 minutes after eating, I kept finding myself in the 70s, and once even in the 60s. I'd chug some more carbs and still be in the 70s an hour later. I saw a couple highs, but none of them lasted more than 40 minutes. So between the insulin and the Teva Metformin ER, my blood sugar seems to be back to where it was when I was a lot younger.

Why this might be is up for grabs. It might be because the new metformin is more potent. Or because the many months of post-meal insulin has given my beta cells a chance to catch their breath.

But there is another possibility. I've been having almost non-stop pain from my shoulder. (The Physical Therapist thinks I might have a significant tear in my rotator cuff, but I can't see the orthopedic surgeon who specializes in shoulders until November 9.) I'm wondering if constant pain might burn out the body's ability to launch a counterregulatory response--the fight or flight thing that pushes blood sugars up when they go low. Up until the past couple weeks--which is when the shoulder went from occasionally twingy to permanently throbbing--when I would get anywhere near the 70s I'd get a sudden burst of counterregulation that would send my blood sugar back up, but that has completely stopped happening.

I'd always heard that stress pushed blood sugars up, but that certainly isn't what I going on here. I'll probably never know what the total explanation is. But for now I'll keep taking the Teva Metformin, though I'd happily give up the continual pain as soon as possible. It's REALLY getting old.

October 10, 2006

Vacation Time!

I'm off to spend a week at the beach with my daughter. Maybe I'll check my email. Maybe I won't. Talk to you all when I get back next Weds.

October 8, 2006

Not all Generic Metformin is The Same!

I've been taking Metformin ER for more than 3 years. When I got them at Stop & Shop's pharmacy, they always gave me big puffy white pills from one of two manufacturers. I noticed one brand seemed to cause a bit of digestive uproar the first day or two I tried it, but didn't notice anything significant in how they affected my blood sugar.

Well this past month I filled my prescription at Walgreens and they gave me a dark pink, dense pill from a manufacturer named Teva. They looked so different from the pills I'd been taking, that I went and looked them up online to make sure that they were, in fact, metformin ER. Based on the numbers on the pills, they checked out as being Metformin ER.

Within two days of starting the new pills, I started seeing dramatically lower blood sugar numbers. Suddenly I was in in the 80s after meals even when I didn't use any insulin (after a low carb breakfast and lunch). I cut back on my insulin at dinner to 2 units max and started seeing 80s and low 90s by 9 PM and fasting blood sugars from 80-89 the next morning every day even with hefty portions of carb at dinner.

When I called the pharmacy the pharmacist insisted that all the generic drugs had to perform the same to be approved, but when I went in, in person, another pharmacist told me that he had another patient who found one brand of regular metformin worked much better for him, too, though the pharmacist didn't say which brand.

To test out whether it wasn't something else causing the drop in my blood sugars, I cut back on the metformin, dropping back to one pill. Immediately my blood sugars went back up about 20 mg/dl. So it looks like it is because of the pink Metformin ER.

I take all 1500 mg at once, around 10:00 in the morning because if I take them at night I find it makes me have to wake up more to pee. My guess is that this particular generic formulation releases the medication more quickly so I'm getting more metformin in my system at once.

OTOH, I didn't see better numbers last year when I was prescribed 2500 mg of Met ER (an overdose, it turns out). That would make me wonder why a higher dose would have that effect. But I was taking that high dose back before I started insulin when my system was really burnt out from trying to normalize blood sugars with not enough insulin being secreted. After almost a year of supplementing with insulin daily perhaps my beta cells have perked up some.

Whatever it is, I'm asking for this stuff next month, too! If you've tried this pink stuff (750 mg Metformin ER) and experienced anything similar, let me hear from you. I'm intrigued!

October 3, 2006

What Can YOU Do to Help People With Type 2 Diabetes?

We all know the feeling, that combination of helplessness and fury we feel when we watch someone we know who has Type 2 diabetes eating the "healthy" meal their doctor has recommended to them that we know is robbing them of health.

For me, the defining moment was when I watched a diabetic friend shovel down a pile of pasta with a drizzle of low fat tomato sauce followed by an apple-laden dessert, only to hear her tell the waitress, "No sugar in the coffee, please, I'm diabetic!"

So what can we do?

I've given this a lot of thought and have come up with what I hope might be a solution. It's a simple support group format that combines methods from two very successful support formats I've been involved in over the years.

The first element in this approach is to teach participants the approach you'll find on Jennifer's Advice for Newbies (The Jennifer who wrote this piece of brilliance is NOT me, BTW!)

It works brilliantly, and even better, because it respects that each person is different and that the diet that works for each person will be different it appeals to people who are put off by any suggestion that they follow any particular diet.

The other element I've drawn on is the support group format pioneered by LaLeche League, a group which has taught women how to breastfeed successfully ever since the days when doctors and hospitals actively discouraged breastfeeding by promoting institutional practices which made it fail. LaLache League pioneered a technique that contradicts what doctors tell their patients without sparking conflict and which appeals to people who don't see themselves as radicals.

LaLeche's technique is to run a cycling sequence of four meetings each one of which puts across a single topic and which leaves room for plenty of interaction between the experienced participants and those who are new to the group. Participants are exposed to the data that shows that their approach is far healthier for mother and baby. Then they are given simple techniques that start them off on the path to success. The basic meeting structure focusses on the essentials. More complex issues are resolved in discussion and by support newbies can get by calling successful peers.

With these successful approaches in mind, the cornerstone of this diabetes support group approach is to focus on the essentials: Teach people what a normal blood sugar is and what the research shows about what blood sugar levels lead to complications. Teach people how to use their meter to find out what the foods they are currently eating are doing to their blood sugars. Suggest to people that if their blood sugar is too high after meals, they can bring it down by lowering their carbohydrate input in whatever way works for them.

Simple, but VERY effective. There's nothing like the look of wonder on someone's face when they report "That oatmeal I ate for breakfast pushed my blood sugar up to 230!" or "Wow! I guess bananas are off the menu from now on!"

Some other, very important basic ground rules, adopted from other very successful support group formats, is that everyone in the group must understand that it is essential for the group's success that no one in the group ever tells anyone else what they should do. What people can and should do is describe their own experience with the focus on what improved their health.

Another important point is to be sure that a "weak leadership" model prevails. The preset format--rotating through the 4 topics--ensures that no one needs to take a strong leadership role and avoids the political infighting which can destroy any group.

Over time, people who have been successful in controlling their own blood sugars may volunteer to mentor newcomers if the newcomers would like someone they can call for help, on the model of the 12 Step Programs.

Here's the complete package:

Start Your Own Effective Type 2 Diabetes Support Group

I'd love to hear your comments!