The A1c is not a good day-to-day monitoring tool, and only reflects average control. Someone could be having highs in the morning and lows in the evening, and their A1c would look perfect. It’s a deceptive measure to depend on.
A diabetic, even a type two diabetic, can’t determine what is and what is not working for their control program unless they have feedback, and that’s the regular blood sugar check. Many oral diabetic medications can - and do- put people too low; other factors come into play too, like illness, stress, changes in routine or sleep, medications, and other factors. There are plenty of things that can interfere with a ‘stable’ type II’s control; that is why frequent spot checks are so important. A knowledgable type II can adjust their diet or exercise routine, or notify their doctor if they start having highs. I know many who do.
And so many type IIs aren’t in good control at all. Also, the definition of what good control means is changing.
The A1c is reflective of average control over a three month period. There are practitioners who only check it on patients they feel are stable every six months. The A1c is most useful with spot checks to put it in perspective…because it’s only an average. And three to six months is WAY too long for someone to be doing damage to their body with high sugars before it’s caught with an A1c. Almost all diabetics need to have the equipment to check at home, need to know how to use it, and need to use it regularly.
My husband is a type II on oral meds, and he tests his glucose 2-3 times randomly during the day on a periodic schedule to make sure that everything is working properly. It’s been very instructive to him and his doc about when and how to adjust his meds. And he’s well controlled. My mom, on the other hands, is type II and utterly unwilling to test her glucose at home, so instead she’s on an incredibly rigid diet and exercise schedule that’s working well for her thus far. Personally, I’d rather stick my finger a couple of times a day occasionally than be quite that rigid, but she’s always been far mor eof a a creature of habit than me.
If there’s one valuable lesson I’ve learned from both of their styles of disease management, however, it’s that you have to use some type of disease management in order to continue to stay as healthy as possible. My aunt, who’s a prime example of an out-of-control type II, will end up losing her eyesight or feet or both or just plain keeling over dead pretty shortly because she fails to stick to any kind of reasonable regimen of either monitoring or diet or anything else (except her regular failure to deny herself any sweets she wants). And imposing a disease maintenance regimen on someone even in a controlled population is not the easiest thing in the world, obviously.
You’re right, it can be a useful movitational tool for some patients. And there’s no question that glucose checks are useful when you’re getting someone’s diabetes under control.
But for the person who has established control and who is otherwise motivated to maintain good habits, there is very little to be gained from multiple daily glucose checks.
To understand my perspective–most of the care I’ve provided in the last four years has been to the poor and the indigent, so I’ve learned to prioritize. Glucose test strips are expensive. I’m also cooking up an article applying the economic concept of rational ignorance to medicine, so I’ve given a lot of thought to the tests we do and what we actually gain from them.
I’m talking about people who are already under good control and already doing the right things and motivated to continue doing so (an admittedly small subset). I do not believe that such a person who doesn’t undergo a big change in diet or activity will have an increase in blood sugar that will cause him significant harm within three months.
This is the last time I post before I’ve had my morning caffiene.
You’re right–it isn’t correct to say that SSRIs work “far better” (and I don’t tell patients that), but anxiety and panic disorders do respond to SSRIs, and I use them as first-line treatment.
My practice is in one of the worst areas of the country for prescription drug diversion. (We are the reason they call it “Hillbilly Heroin”.) When I first started, I was far more liberal with benzos like Klonopin than most docs around here. After a few months, once the word got out among the surprisingly organized drug underground in this area, I noticed that every single day–every day–I had anywhere from six to ten new patients describing panic attacks and generalized anxiety, all of them asking specifically for Klonopin because they knew I preferred it to Xanax.
So the only way I can keep from drowning in drug seekers is to severely limit my use of benzodiazepines. People who come in describing a generalized anxiety or panic disorder are strongly encouraged to seek counseling and given the option of starting on an SSRI, but those who require benzos (or who say they do) have to be referred to a psychiatrist (who are unfortunately limited around here).
Believe me, if you have a better approach, I’d love to hear it, because I want to be able to help the people who I can really help. Meanwhile, I’m going to stop crapping on Qadgop’s thread, which was far more interesting before I came along.
Heh. Our corrections system’s mission is to eliminate the use of benzos for psychiatric complaints in 99.99% of the cases, for reasons similar to what DoctorJ mentions above. Fortunately that job falls on the psychiatrist, not on me.
70% of my patient population has a substance abuse history.
And I’m still pitting homicidal killers who lie about their blood sugars! Also child molesters who play basketball in the gym but demand I give them a lower bunk because their knees bother them! And guys who commit barratry who insist that moisturizing cream is medically necessary to keep their skin supple!
In criminal and civil law, barratry is the act or practice of bringing repeated legal actions solely to harass. Usually, the actions brought lack merit.
In admiralty law, barratry is a fraudulent act committed by a master or crew of a vessel which damages the vessel or its cargo, including desertion, illegal scuttling, and theft of the ship or cargo.
The buying and selling of positions within civil authority.
Most of my patients who are Barratrists (Barratricians?) are so under definitions 1 or 2, or both. Occasionally we get someone guilty of 3.
I don’t doubt that your patients have said that or that they’ve been drug seeking. However, I also know friends who have said the same thing (well, without the remoulade example), and they haven’t been looking for Xanax to sell on the street. Pretty much, they’ve expected SSRIs to work immediately (like Xanax or Klonipin) and don’t realize they may have to wait 4-6 weeks to see an effect or that the particular dose/drug may not be the right one, so they have to wait longer.
That’s why (as you said), it’s best to refer them to a therapist and psychiatrist. When I went on SSRIs years ago, I couldn’t tell after three weeks that they’d done anything. When I told my therapist that, she laughed at me and described just how terrible my anxiety had been three weeks prior compared to where it was now. I just wasn’t noticing because it wasn’t all gone yet. My psychiatrist was also able to see a difference (though he did say after the first month we’d have to up my dosage) as well as describe what to expect, how long before I’d see effects, the side effects, what types of reactions were very bad and would require a call to him. In addition, he did perscribe Xanax to get me through the initial panic attacks. However, he gave me very explicit instructions on how to use it, gave me a non refillable perscription, and details how/when I was to take it in order to avoid addiction.
Qadgpod , thanks for sharing your perspective. Some things are never seen by John Q. It is good to see what someone who lives it thinks.It is amazing that those who are supposed to be paying their debts are so cavalier in thier actions. Really , I guess it isn’t . If they had a conscience , they wouldn’t expect everyone to pay for their crimes.
