Post cards from the edge of the epidemic
The silence has gone on too long. I’m frantically searching my brain for a solution, any solution to the problem. But I don’t have the tools I need to fight this. The 13-year-old sits quietly, staring at his hands. His mother fidgets. I’ve got his log book in my hand. On my computer, the screen is open to the Assessments page of the electronic medical record.
I have to enter a Dx code. On his first visit I coded him as a diabetes screening. On his second I coded him as unspecified glucose intolerance. But now, looking at his log book, I know what I have to do. He’s got two “Hi” readings. The meter isn’t being friendly. Plus three or four in the 400s. I sigh and pull the key board to me and enter 250.00; he’s now officially and for all time a Type-2 diabetic. I extend my hand to him, “welcome to my club.”
The club is growing at an alarming rate. It all came from our school screening that I wrote about a few weeks ago. Now I’m suffering from the fall out, and I’m seeing the same thing again, and again, and again, and again. Kids with complete first phase insulin response failure. They wake up in the morning at 88 BGL. Then they eat. Then they rocket up to 200, 300, 400, 500, or “Hi.”
So how the fuck do I treat this? These are not T-1s, remember. And I can’t use the one drug that would probably help. Byetta.
Byetta would… sorry… does restore first phase insulin response. It would be perfect. It would knock the sugars down, give the pancreas a break, and has no real risk of hypos. But its not approved for under 18. We could give it off-label if any of these kids were rich. But they’re not. This is a very poor part of the world. Most of these parents have a hard time keeping the heat on in the winter, much less pay for God-awful expensive drugs.
To be fair, I gotta say, Amylin has been super about providing Patient Assistance Program drugs to my adults. Thousands of dollars of Byetta has flowed into our clinic via PAP to help those over-18-years-of-age patients of little means.
AvandiaRoulette and Actos are also not options, the kids are too young again. I can use Metforim, but why bother? It doesn’t treat the problem I’m facing.
That leaves me with only one arrow in my quiver: NovoLog. But do I really want to put dozens and dozens of early teens on fast-acting insulin? Many of these kids are immature. The one in my office, although calm at the moment, is medicated for attention deficit disorder. He also plays with matches and starts fires, according to his mother.
He’d kill himself on insulin.
But if I do nothing the diabetes will take decades off his life.
I have to enter a Dx code. On his first visit I coded him as a diabetes screening. On his second I coded him as unspecified glucose intolerance. But now, looking at his log book, I know what I have to do. He’s got two “Hi” readings. The meter isn’t being friendly. Plus three or four in the 400s. I sigh and pull the key board to me and enter 250.00; he’s now officially and for all time a Type-2 diabetic. I extend my hand to him, “welcome to my club.”
The club is growing at an alarming rate. It all came from our school screening that I wrote about a few weeks ago. Now I’m suffering from the fall out, and I’m seeing the same thing again, and again, and again, and again. Kids with complete first phase insulin response failure. They wake up in the morning at 88 BGL. Then they eat. Then they rocket up to 200, 300, 400, 500, or “Hi.”
So how the fuck do I treat this? These are not T-1s, remember. And I can’t use the one drug that would probably help. Byetta.
Byetta would… sorry… does restore first phase insulin response. It would be perfect. It would knock the sugars down, give the pancreas a break, and has no real risk of hypos. But its not approved for under 18. We could give it off-label if any of these kids were rich. But they’re not. This is a very poor part of the world. Most of these parents have a hard time keeping the heat on in the winter, much less pay for God-awful expensive drugs.
To be fair, I gotta say, Amylin has been super about providing Patient Assistance Program drugs to my adults. Thousands of dollars of Byetta has flowed into our clinic via PAP to help those over-18-years-of-age patients of little means.
AvandiaRoulette and Actos are also not options, the kids are too young again. I can use Metforim, but why bother? It doesn’t treat the problem I’m facing.
That leaves me with only one arrow in my quiver: NovoLog. But do I really want to put dozens and dozens of early teens on fast-acting insulin? Many of these kids are immature. The one in my office, although calm at the moment, is medicated for attention deficit disorder. He also plays with matches and starts fires, according to his mother.
He’d kill himself on insulin.
But if I do nothing the diabetes will take decades off his life.
posted by Wil | 7:19 AM
7 Comments:
I don't envy your position, having to label them as having type 2 diabetes in the big brother computer health care system which will mean they'll almost never be able to get insurance on their own for their entire lives (did you see Sicko?). But it's the only way you can get medication for them.
Did you happen to see the Shaq's Big Challenge reality show on tv this past week about children battling obesity? Nearly everything the trainers did went against all philosophy for empowering kids who need help.
You will empower your patients. You have a huge heart and your patients are so lucky to have you in their lives.
Our country needs a transformation on an atomic level to develop preventative health measures. Let the grass roots begin to grow.
Wil- I'm not trying to be rude or anything, but maybe you can help me understand something. IIRC, you aren't a doctor or an NP or a PA. So why is it your job to make the diagnosis and decide what medications to use?
Also, correctly me if I'm wrong here too, but can't 250.00 also be used for "diabets not otherwise specified?"
The most recent research showed that Byetta failed to do much for 70% of those who took it.
What you CAN do is instruct these kids that it is the huge amounts of carbohydrate they are eating that is raising their blood sugar!
Their normal fastings are the tipoff that it is the carb that is the problem.
If they can learn to eat, say, 30 grams a meal, as opposed to 100-150, they can still get normal numbers and they may be able to rescue their beta cells.
There are literally hundreds of folks who have done this, starting out with extremely high bgs and getting back to normal.
So do try to educate them about what a carbohydrate is, how many grams of carb is in a portion of the foods they are eating, and what they can eat instead. It could save their lives!
Megan—
Not rude. I had considered explaining that in greater detail, but it seemed to mess up the flow of the post. Entering a Dx into the computer is simply data entry, no different than entering the patient’s phone number. It just happens to be one of my jobs is to enter the various diabetes codes based on the clinic’s standards. You can use 250.00 to serve as any kind of T-2. The “not other wise specified” refers to control status. We can also specify controlled or uncontrolled. Although we never use them, there are also assorted arcane codes for detailing complications.
I’m not a Doc, but like most Diabetes Educators, I have been granted pretty wide authority by my boss under his license. Made me a nervous wreck at first. Medication wise, it is my responsibility to create treatment plans. They are then reviewed by people who are smarter than me and have more letters after their names than I do. I recommend the most appropriate med and write a script. The script then goes to one of the providers to review and sign off on. Unless a med choice is counter-indicated by other health problems beyond the diabetes or med interactions, the plan is usually approved. So it’s not like I’m a lose cannon. More like a cog in a finely oiled machine.
It is a lot of responsibly which I take very, very seriously. I have two advantages over the providers that makes me comfortable. I only do diabetes work. They have to deal with the entire scope of medicine. Second, I get the luxury of spending an hour with a patient, even more if I need it. The providers rarely get more than 12 minutes.
Wil
PS: to Jenny, we’ve had astounding results with Byetta. But for the kids, I’ve just hired a guy whose entire job will be working with the kids on nutrition and diet. We’re working hand-in-hand with the school system, our screening data really opened up the doors.
Some of those kids go to my school -- most are immigrants, but that is only because the intake center caught them.
Because of communicable diseases, immigrants (legal and otherwise), get a full and complete physical.
So maybe Byetta can use your kids for a clinical study. Seems there might be a big market share in the making.
Kathleen,
Then who will pay for the Byetta if it's approved for those kids?
Seems like the military lobby is able to get their hands on more money than the health/diabetes lobby. Don't think we'll see any money for that for quite some time.
Some of this kid's ADHD symptoms could be from the BG rollercoaster he's on.
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