Hard calls to make

Once, many years ago, I found myself in the position of calling my wife to tell her I was in the Emergency Room.

Ummm…. Hi, Hon. It’s me. Uh, I don’t want you to worry or anything, but I’m calling you from the ER…

And the conversation went pretty much downhill from there.

Now imagine making thirty calls like that. That was my day yesterday, after the FDA announced an ongoing safety review of the type 2 med Actos.

Actos is a member of the TZD family, anti-insulin-resistance drugs that are designed to allow the body to more efficiently use its own insulin to control blood sugar. The other member of the TZD family was Avandia, now effectively banned worldwide. Avandia was actually a great diabetes drug. It did an awesome job controlling blood sugar. The only problem was that whole nasty side effect that it might maybe give you a heart attack.

(((Sigh)))

Actos is under fire for a different reason, for might maybe increasing the risk of bladder cancer. The evidence isn’t 100% clear, but strong enough for France to yank if from the market, and strong enough for Germany to ban new prescriptions.

Here in the U.S., where it’s nearly impossible to get FDA approval of a new med, it’s equally impossible to get rid of one once it’s approved. The FDA is at the five-year point in a ten-year looksee at Actos. At this point the FDA says overall risk of bladder cancer for folks who use the med isn’t higher, but an increase in bladder cancer was noted “among patients with the longest exposure” and in those “exposed to the highest cumulative dose.”

Excuse me?

So…. We just need to wait a little longer for everyone on Actos to get cancer, is that it?

Anyway, the five-year data, and a French study, are strong enough for the FDA to change the infamous “Warnings and Precautions” section of Actos’ label. The exact wording isn’t published yet, but the lead sentence of the safety announcement gives us a pretty good clue: “Use of the diabetes medication Actos (pioglitazone) for more than one year may be associated with an increased risk of bladder cancer.”

I guess the new Actos ads will tell us, “call your doctor if you experience bladder cancer.”

Holy crap.

The FDA also cautions docs not to use Actos in patients with active bladder cancer, past bladder cancer, or in persons with a family history of bladder cancer.

I predict a free-fall drop of Takeda stock.

“What do you think?” one of our Docs asked me in the hallway.

I’m soooooooooooooo done with these TZDs, I told him. I think we should just pull all our patient’s off of them. It’s not like we don’t have an entire medicine chest of other options. Why wait for trouble to be official?

“Do it,” I was told.

So began to make my phone calls. Yeah, hi, how are you today? Yep. Uh-huh. Uh-huh. Say, are you still taking your Actos? Yeah? Well, OK, I want you to stop…

I started with my most-excitable patients first. I knew by the time I called the third person, the first person would be calling all her diabetic relatives. I wanted the ones most prone to panic to hear it from me first. In terms of speed, social media on the internet is nothing compared to little ol’ ladies with landline phones in small towns. We call it the Viejita-Net.

I told them what was up. Not to panic. That we were being overly cautious. That the drug would linger in their systems for a week or so, and then their blood sugars would begin to climb. I reminded them that short term, higher blood sugar wouldn’t harm them. I asked them to test their blood sugars intensively for a week after that, then come see me.

The plan is to choose successor therapies based on each person’s Actos-free blood sugar patterns. Some will get DDP-4 inhibitors. Some will get basal insulin. If you’d asked me on Monday, I would’ve leaned towards using Victoza for many of them, but just a few days ago a much stronger thyroid cancer and pancreatitis warning was issued by the FDA about that drug too.

(((Sigh)))

I let the front desk know what was going on, and why I’d be transferring so many patients up to them to make appointments. “Wait a minute,” asked the medical records clerk, “Isn’t that the drug we moved all the people who used to take Avandia to?”

(((Sigh)))

Yeah. Yeah, it sure is.

At least at the ER they gave me a heated blanket and a heated pillow.

Of Words & Deeds

The color of diabetes. Deep red. Like blood. Moving, spinning, flowing. I swirl the glass in my left hand, gripping the stem lightly, watching the fluid rise and fall around the clear edge, slowly settling back into the bottom, not wanting to let go of the smooth surface.

Rio cocks his head to one side, waiting. I bring the wine glass to my nose and breathe in the aroma. Ahhhhhhhhhh…. A lovely cab.

I raise my glass and say, “to words and deeds.” Tonight we are celebrating.

Rio clinks his Roy Rodgers against my wine glass and repeats with delight, “to words and deeds!”

His mother raises her margarita glass, clinking it against both of ours; our three different drinks uniting in one toast like the Three Musketeers. “To words and deeds,” she repeats.

Tonight, we have much to celebrate.

Where to even start? Well, Rio survived second grade. Barely. But he won a science award, which came as no surprise; and he also won a most-improved reading award, which was a surprise. Rio’s lagged far behind in reading since pretty much day-one, not from lack of brains, but from lack of seeing any value in reading. (Don’t get me started.)

After coming home from the school awards banquet he proved he inherited some genes from his paternal grandmother. “Don’t awards require a celebration?” he asked, and then set the bar high by suggesting the Steaksmith in Santa Fe would be the most appropriate place to go.

“We do have other awards to celebrate too,” pointed out Debbie.

True. I haven’t posted about them yet, ‘cause I didn’t want LifeAfterDx to start looking like a resume. But I’m kinda proud of this, so just really quickly, my CGM book Beyond Fingersticks has now won:

Yep. Three, count ‘em T-H-R-E-E awards. Oh and the little Tiger book also won a second award this season too. That brings my book award tally for the three English Language books to eight, three for Born-Again Diabetic, two for Taming the Tiger, and three again for Beyond Fingersticks, which gives me resume bragging rights to say: “Author of three multi award-wining books.”

My mother is very proud of me.

But not all the action is in books. Lots of other cool things are happening with Words in my life right now. Of course all of you are up to speed with my work answering diabetes questions at ShareCare, and hopefully you’ve been following my Dear Abby-style advice column on Saturdays at Amy’s Diabetes Mine site.

What you might not know yet is that I’m now writing for dLife too.

If ya’ click on that logo on the left it’ll take you to my profile page that will eventually link to all my work there. Right now there’s a piece up about how many times you could/should use a needle. My Debbie once left a pen needle on a Byetta pen for a month, that’s sixty shots! (No, we’re not quite that poor, apparently I was unclear when I taught her how to use the pen—at least that’s her story, and she’s sticking to it.)

If you search a little, you might also find a piece I did on the importance of dental cleanings, with a unique twist.

So you might ask, does he ever sleep? And the answer is: of course. Just not very often or for very long. ;-)

Seriously, don’t worry about me on that front. I’m still in the trenches at the clinic, but now running a much smaller program. Not that we have fewer diabetes patients, in fact, I had two new ones just this week. One of them cried when I told him he had diabetes. But that’s a story for another day. As is the one about the guy in a wheel chair with one leg that has no electricity or indoor plumbing. Did I mention he has to travel 200 miles three times per week for dialysis? If that one won’t make you cry, the one about the 13-year-old type 1 whose father steals his syringes for heroin will. Where’s the mom? Pissed if a low blood sugar makes her late to go party, that’s where.

Like I said, we’ll have to save those for another day.

No, our program is smaller ‘cause grant funding is drying up. Well, hell, funding for rural health of any kind is drying up. It seems the folks who sit in the comfy leather chairs in DC really don’t care if poor people with beautiful skin colors have health care or not.

Sometimes I even think they’d rather just let everyone who’s not like them die.

So my program is down to just me, and just three days per week. Still, that’s three-quarter time on our ten hour days, and I find now that I’m getting older, the long days and long commutes really wear me down. I’m liking the Monday-Wednesday-Friday thing just fine, thank you very much. It gives me all day Tuesday and Thursday to write, and my loved ones are not exactly early risers so I have peace and quiet for hours on weekends to boot.

So life, in the big picture is good. Sure. I still struggle with my diabetes. My check book. The little annoyances of life, like the fact that I spend about of a third of my time fighting with the fucking insurance companies, rather than just helping my patients to understand how to help themselves be healthier. But, still, life is good. I love my work. The one-on-one with the people I can look in the eye; and the work with people I can only reach through my Logitch Wave keyboard.

Life, in the big picture, is good indeed.

Where’s that cocktail waitress? I think I’ll have a second glass tonight…

Good morning Mr. Dubois, we’re calling to tell you that you’re screwed

There oughta be a fucking law… well, come to think about it, there oughta be a lot of fucking laws. So today, Edgepark, the durable medical goods outfit who is the preferred provider for my Presbyterian health plan called me.

It turns out that my plan stopped covering one of my common insulin pump supplies.

A year ago.

Pres didn’t tell me.

Pres apparently didn’t tell Edgepark.

Edgepark apparently didn’t pay attention to the fact they weren’t getting paid for a year.

And now guess who gets stuck with the bill?

Yes. That would be me. The guy who can’t even afford to buy a full tank of gas for his Jeep in this economy. Oh well. What’s one more bill between friends? It’s not like I was planning to retire. Ever.

But what really makes me mad.. well, madder… is the whole process. The lady from Edgepark tells me that the official line from the insurance company is that “verification of benefits is not a guarantee of payment.”

Excuse me?

Ummm… now wait a minute. I’m stretching my infusion sets to four days ‘cause I know with 100% certainty that my quarterly shipment of keep-me-alive supplies will be held up for weeks while everything from my blood type to my doctor’s great-grandmother’s maiden name is confirmed, double checked, re-verified, and approved.

And all these delays and bullshit and stress and frustration are for… nothing?

I could just scream. In fact. I think I will.

Excuse me while I step outside for a moment.

Well, now I feel better.

No. Wait a minute.

I don’t.