Bernard's Diabetes Blog

The artificial pancreas

noreply@blogger.com (Bernard) — Sat, 10 May 2008 14:36:00 +0000

You may have already heard about the JDRF artificial pancreas project.

They're working on developing a closed loop system where readings from a continuous glucose monitor (CGM) are used to directly control an insulin pump. Currently those of us with CGMs and insulin pumps have got an open loop system, we need to take the readings from the CGM and decide whether we need insulin or food.

Clearly this is a difficult problem to solve. How would such a system know if you were sick? What would it do when you're about to exercise? How would it handle changing insulin needs for children who are growing?

Now you have a chance to learn more about this project. On July 21st and 22nd the FDA, NIH and JDRF are holding a public workshop 'focused upon the state of the art in the research and development of an artificial pancreas'.

The meeting will be in Bethesda Maryland at the NIH campus. Building 38A on this map. Space is limited so you do need to register.

I would love to go to this workshop, but I'll be out of the country.

Can I ask you a favor? If you go the workshop can you write up a summary of what's discussed and post it to the blogosphere?

Attribution: The illustration above is from the JDRF site.

Dexcom Open Choice

noreply@blogger.com (Bernard) — Thu, 01 May 2008 01:43:00 +0000

My local Dexcom rep kindly arranged to give me a loaner of the new Dexcom Open Choice system. The main difference with this system is how it's calibrated - you can use any meter and enter the blood glucose values by hand.

I carried around both Dexcom receivers, the Dexcom 7 and the Dexcom Open Choice, for over a week. In this test I set them both to read from the same transmitter, so I could directly compare the results. Here's a short video that shows how to calibrate with the new system.

Below I've also got some details comments on the pros and cons of the changes.

I think this small change is a major improvement to the Dexcom system. It gives you the freedom to use your favorite blood glucose meter, so you don't have to worry about getting insurance coverage for two sets of test strips. The WaveSense Keynote meter that I used is extremely accurate, so I hope to benefit with better control and tighter A1Cs.

Dexcom updated their software so that the modal view is available once again. You can now see the reading graphs for up to nine days of readings. I've used this to see problems that happen at specific times each day. It was the only thing I missed from the first version of the Dexcom software.

I have two minor issues with the new features.

First when inputting the glucose value you use the up/down arrows to change the existing value shown by the Dexcom. The scroll speed for those arrows is much too fast. Most of the time the current value is going to be close to the reading from your meter. So you need to change the value only a little. The scrolling is so fast that it's only useful if the difference is over 100 mg/dL. Dexcom please reduce the speed here.

The other issue is even less important, it's to do with the location of the calibration screen. After you've removed and replaced a sensor the first thing you need to do is tell the receiver. You use the sensor insert screen that only appears when the receiver isn't already connected to a transmitter. Dexcom placed this screen after the calibration screen. It should be placed before the calibration screen. Most users will not be calibrating without a sensor in place.

The Dexcom Open Choice is being shipped to all new customers. Existing customers can pay an upgrade (about $200 currently). Dexcom is waiting for FDA approval to provide a download capability for software upgrades. The hope to get this approval by July and will then provide the upgrade for free to existing customers.

Note: I currently own shares in Dexcom, I try not to let this ownership influence what I say about the company or its products.

2nd Annual DiabetesMine Design Challenge

noreply@blogger.com (Bernard) — Wed, 30 Apr 2008 15:07:00 +0000

Amy Tenderich has announced another diabetes design challenge.

Last year Amy wrote an open letter to Steve Jobs. The design company Adaptive Path took up the challenge and created a design concept for a new device called Charmr.

Recently Medgadget (co-host of the competition) reported on some diabetes device design work by Sascha Morawetz.

This year the challenge has two prizes. $1,000 for 18 and over and the same for those under 18. The competition is open until May 26th. Read Amy's blog for full details.

Designers, ask someone you know with diabetes about the devices they use several times a day. The 'design' is close to awful. Some of the newer devices are an improvement, but very small. Look at the market reaction to the UltraMini blood glucose meter, and that's just because it's got a cute shape and is available in colors.

I do hope this year produces some designs that will make it into real devices. I can't wait to watch the entries on YouTube.

OneTouch UltraLink meter

noreply@blogger.com (Bernard) — Tue, 29 Apr 2008 15:08:00 +0000

We finally have a replacement wireless meter for the Minimed Paradigm insulin pumps. The new model is the OneTouch UltraLink meter.

It uses existing OneTouch Ultra test strips, with 5 seconds before you have a reading. The meter lets you flag readings as before or after meal so you can get these averages. It stores up to 500 readings and runs on 2 AAA batteries. For more details read the 90-page user's manual (PDF).

The meter is now being shipped with new Medtronic Paradigm insulin pumps. Those of you who already have a Paradigm pump will have to wait a little longer.

According to the Medtronic FAQ page for this meter

... we plan on sending U.S. customers who own a MiniMed Paradigm 512, 712, 515, or 715 insulin pump a OneTouch� UltraLink� Meter at no charge later this year.

Minimed gives you a way to find out when you'll get your meter.

This meter is only available to US customers. Outside the US, the replacement meter will be from Bayer. Currently there's no word on the release date for the Bayer wireless meter.

If you have, or want to use, the OneTouch diabetes management software you'll need the latest version (2.3.2). You'll also need to download the newest meter driver to your PC so the UltraLink can be recognized.

New diabetes search sites

noreply@blogger.com (Bernard) — Wed, 23 Apr 2008 09:53:00 +0000

It's been a while since I did this.

The diabetes search engine now has about 900 sites and pages that it searches for information all about diabetes. So far the advertising revenue is about $55 and that's all going to Dr. Faustman's research at MGH.

Here's some of the sites that I just added recently.

The misadventures of peabody is a new blog from emily who was diagnosed with type one in March 2008. That's about seven weeks ago. Drop by and welcome her to the diabetes OC.
The ultimate hike for a cure! Ty Hover is either crazy or wildly ambitious. He's planning to hike from Detroit to Alaska and raise $290,000 towards diabetes research along the way.
sugar free musings is Dae's blog. You may also know her from her excellent Diabetes365 pictures.
The lucky druggie is a blog by Jessica who was diagnosed in January 2007. Today is her 19th birthday, drop by and say hi to her.

Diabetes365

There are now over 4,500 pictures in the Diabetes365 project with more being added every day. Several have been used by the media.

If you'd like to learn how diabetes affects us or makes us feel drop by and have a look. If you do decide to use a picture for any reason, do please ask the photographer and give attribution.

Delighting the customer

noreply@blogger.com (Bernard) — Sat, 19 Apr 2008 03:45:00 +0000

I use this term for a product that you may already like that then surprises you with a feature that you didn't even know existed. Like a car that turns off the interior lights before the battery runs dead, even if you'd left them on by accident.

I had one of those experiences today with my Cozmo. Yesterday my pump had started to complain that the battery was almost empty. And today I was running on voltage fumes.

I knew that I had to replace it, but I kept forgetting to. That is, until I was putting in a combination lunch and correction bolus. While the pump was delivering the bolus I decided to test what would happen if I removed the battery, essentially mimicking loss of power.

After replacing the battery I was pleasantly surprised to see a Bolus Interrupted message on my Cozmo. This is the kind of attention to detail that I've seen in other parts of the Cozmo pump. Those firmware engineers (the folks who write the code that runs the pump) really thought about this - good for you folks!

Dexcom delights

Another customer delight for me, this time from those great Dexcom folks. Today I got the new Dexcom CGM model to try out for a week or so (one sensor life). I'm going to replace my 16-day old sensor this evening and tomorrow I plan to try and use both receivers against the same sensor and see what happens. I'll use the OneTouch meter with the older receiver and my AgaMatrix WaveSense meter to calibrate the newer receiver.

What I'm hoping is that the newer receiver will show my readings to be higher that on the older receiver. If I'm right then it may prove my theory for my A1C being higher than expected.

The trial model also came with the slightly newer version of the Dexcom software. They've re-introduced the modal day view, which is very useful when you want to see recurring patterns in a number of days.

I'll blog about the new receiver and software after I've had a chance to play with it for a few days.

Note: I currently own shares in Dexcom, I try not to let this ownership influence what I say about the company or its products.

Oramed starts phase 2A trials on insulin capsules

noreply@blogger.com (Bernard) — Wed, 16 Apr 2008 22:41:00 +0000

Yesterday Oramed Pharmaceuticals announced they are starting phase 2A trials on their oral insulin capsules.

The capsules are being tested at Hadassah Medical Center in Jerusalem on 10 patients with type 2 diabetes.

Phase 2 is where potential drugs are tested to see if they're safe and they work (efficacy). The capsules will need to complete a phase III trial before they can be sold to people with diabetes.

The main challenge to taking insulin by mouth is that the insulin protein is broken down in the stomach before it has a chance to be used by the body. Oramed claims to have solved this problem and the challenge of getting the insulin through the walls of the intestine.

According to their website

Prof. Hanoch Bar-On, a leading Diabetologist on the Oramed team, states that the route of the insulin from the swallowed capsule �imitates nature� in that it passes to the liver and then to the bloodstream. Injected insulin goes straight to the bloodstream.

I've been unable to get any information on dosing (figured out in phase 1B) or the duration of insulin delivered by the Oramed capsule. I hope to get this after phase 2A is completed. It took Oramed about seven weeks to complete phase 1B, so this information may be available sometime after mid-June.

Oramed is planning to get approval first in the US and then Europe.

In addition to their oral insulin capsule, Oramed is also working to develop an insulin suppository. This product is in Phase 1 trials at present.

Update: I exchanged some e-mails with Oramed. They told me that the phase 2a trials are 'expected to last a few months'. Also that while the trials are on people with type 2 diabetes the product may be usable by people with type 1. I'll post again once I have more news.

Type 1 Diabetes Awareness Day

noreply@blogger.com (Bernard) — Mon, 14 Apr 2008 10:40:00 +0000

Today I'm joining other folks with type 1 diabetes to make a little noise about it.

This used to be called juvenile diabetes because most people were diagnosed before they ended their teens. But now it's clear that you can get it at any age.

When you get type 1 diabetes, your pancreas has stopped working properly. This organ contains cells that create insulin, glucagon and other hormones. The insulin is needed so the cells of your body can process the blood sugar created whenever you eat food containing carbohydrates. Without insulin your blood sugar increases and there's no way for your body to use it.

What are the symptoms for type 1 diabetes?

Extreme thirst. This is the most obvious one. My mother described it as "wanting to drink out of the toilet bowl". Think about drinking several glasses of water and still feeling thirsty.
Lots of peeing. That's because of the water and your body trying to get rid of the sugar floating around your blood stream. Your urine is actually sweet. Mellitus (as in diabetes mellitus, the medical term for type 1 diabetes) is the Latin word for honey.
Extreme loss of weight. You've got sugar in your blood, but your body can't use it. So it breaks down its energy reserves (fat). One of the by-products of fat break is ketones. The night before I was first diagnosed with diabetes I lost over 10 pounds.
Extreme hunger. Even though you've got all this sugar in your system, your body can't digest it so you feel hungry.
Blurry vision. The density of your blood changes. This changes how your eyes focus.
Slower wound healing. Instead of clearing up in a few days a small cut or scrape can take over a week, or even longer. When I was diagnosed I had a cut on my toe that was over three weeks old. Once I started on insulin it disappeared in about five days.
Fruity breath. This is from the ketones. It tastes fruity and the smell may remind you of nail polish remover. Dentists often diagnose diabetes due to this smell or .
Itchy genitals. That sugar in your urine can cause urinary tract infections.
Fatigue. The extremely high blood sugar can cause urinary tract infections.

If you see several of these symptoms please contact your doctor. Untreated diabetes can cause coma and ultimately death. This is serious business.

These days the tools for treating diabetes are pretty good. But it still takes a lot of support and help to really manage living with diabetes. Don't try to do this alone.

If you've already got diabetes there's lots of useful places online where you learn more about taking care of yourself and your diabetes. Try the Diabetes OC for a list of diabetes blogs. TuDiabetes.com is the first of many other social networking sites for people with diabetes. There's even a weekly television program for diabetes, dLife.

I created a diabetes search tool to make it easier to find diabetes information online. I use the advertising revenue to support the research by Dr. Denise Faustman into a possible type 1 diabetes cure. To date, I've raised about $50 for this cause.

If you've already got type 1 diabetes, today is the perfect day to raise awareness. Do people at work know how to treat you if your blood sugar goes low? Can you share information about living with type 1 on your blog, or maybe an article in your local newspaper? Do your best to spread the word.

For today, I'll be using Twitter every time I do something due to my diabetes. This way others can see what I do to control it, and maybe learn more to help themselves or others.

Have a wonderful Type 1 Diabetes Awareness Day.

And why not give a hug to anyone with type 1 diabetes today?

Friday things

noreply@blogger.com (Bernard) — Sat, 12 Apr 2008 03:29:00 +0000

The second part of the blogger roundtable series has been published on the JDRF site.

This time we're all talking about insulin pumps. How we first got on an insulin pump, what the challenges were, and other things about being partially bionic. It's a great read.

Thanks to Allison for putting this series together.

In other news, next Monday is Type 1 Diabetes Awareness Day

This is the day where you try to tell others a little more about type 1 diabetes and what it's like to live with it.

Beth has put together a really nice diabetes handout. Maybe you can print up some copies to hand out to folks.

If you use Twitter, maybe you'd like to tweet about diabetes for the day.

Or perhaps finally tell that friend that yes it is okay for you to eat cake or ice cream, and explain why it's none of their business.

Whatever you can do to let people learn a little more about diabetes helps us all. And that may help you.

Enjoy the weekend.

My alleged heart attack

noreply@blogger.com (Bernard) — Wed, 09 Apr 2008 21:40:00 +0000

To stop you from worrying I have not had a heart attack. Or any inkling of one.

Recently when I saw my excellent endo we had a discussion about whether I should continue to take a statin to reduce my cholesterol.

I've been taking Lipitor for about a year. I changed my use of the medicine (this may not work for you) from a 10mg pill every day to half of a 10mg pill every other day. I see a substantial reduction in my cholesterol level with this dose and I don't seem to have any of the possible side effects, thank God.

But a while ago, I read news about investigations into the benefits of taking statins. This was why I had the conversation. I was especially taken by the quote from the NY Times article.

"If a patient has had a heart attack," Dr. Afilalo said, "they generally should be on a statin."

For people who haven't had a heart attack the investigation showed there isn't as much evidence that taking statins provides a substantial benefit to enough folks to justify everyone taking it.

I was shocked by her response. "But you've already had a heart attack." For a moment I thought I was in an alternate dimension. I reminded her that I'd not actually had one. She told me that type 1 diabetes increases my risk of heart problems. Just as much as if I'd actually had one. Yikes.

Now I do really like and respect my endo. I've moved medical offices to follow her from Massachusetts to New Hampshire. But I still like to verify what I'm told, it's my natural cynical nature.

Then earlier this month I saw this news report. She was right! A recent study found that folks with diabetes (both type 1 and type 2) have double the risk for a heart attack.

So for now I'll be staying on my statin and living with yet another drug to reduce the risk of "bad things" happening in my future.

Attribution: This beautiful picture was taken by Conny. She retains all rights to the image and I'm grateful to her for letting me use it in this post.

What I'm up to

noreply@blogger.com (Bernard) — Sat, 05 Apr 2008 02:48:00 +0000

It's been too long since I blogged here.

My intention is to maintain this blog for review of diabetes devices and comments on usability and future technology trends. Currently I'm hoping to review the Pelikan Sun device, once I can get my hands on one.

In the meantime, I'm still writing posts on my Diabetes Daily blog. I've recently started a daily set of NaBloPoMo posts focused on letters.

With luck and effort I can make it through the entire month of April. So please follow me there.

Type 1 cure trials start

noreply@blogger.com (Bernard) — Fri, 14 Mar 2008 00:51:00 +0000

This is the most exciting news I've had since my diagnosis with diabetes 25 years ago.

Today ClinicalTrial.gov posted a trial announcement looking for people to participate in the first trial for a possible cure for type 1 diabetes. This is based on the research led by Dr. Denise Faustman over the last decade.

To quote the site "This is the first step in trying to cure established type 1 diabetes". Tell me that's not a big thrill.

When I spoke with Dr. Faustman in January, she was hoping that they could trial this approach with relatively small numbers of people. It seems she was successful, they are looking for 25 subjects to participate in this trial. Dr. Faustman mentioned that the early trial would be used to try and establish basic dosing information and determine whether the approach actually works in people.

As usual for this type of trial there will be two groups of participants, some taking BCG and others taking saline as a placebo. You would receive an inoculation at the start and at 4 weeks into the trial. It's a double blind trial. Neither your nor the investigators will know who's receiving which substance.

BCG has been used for many years as a vaccination for tuberculosis. It's also used in immunotherapy for cancer and other diseases. It's low cost, approximately $3 for a tuberculosis vaccination. It's also not 'owned' by a specific pharma company, so it should be readily available.

I would sign up for this trial today...but I don't qualify. My age and previous inoculation with BCG exclude me. I do hope that's not always the case.

If you're thinking about it, please take a close look at both the inclusion and exclusion criteria. There are a lot of these.

We're definitely living in exciting times.

Abbott FreeStyle Navigator is approved

noreply@blogger.com (Bernard) — Thu, 13 Mar 2008 13:16:00 +0000

Today Abbott reported that the FDA has (finally) approved the FreeStyle Navigator continuous glucose monitor(CGM) for sale in the US.

This is one of the most anticipated CGM devices. Many people I've spoken with have expected that this CGM will solve all the shortcomings of the Dexcom and Minimed devices. I've also talked with several people who have been using the Navigator. My take is that this is no more perfect that the existing CGM alternatives.

Abbott, who even has a special site for the Navigator, says that it will be available in the second quarter of 2008. Like all CGMs you will need a prescription to get hold of one.

A few interesting aspects of the Navigator:

Five-day sensor.
Five direction arrows to indicate rising or falling blood sugar
The receiver has a built-in FreeStyle meter.
Designed to 'accomodate' swimming. Does that mean the receiver is waterproof?
The receiver can be up to 10 feet from the transmitter

You can see a short movie illustrating how the system works. It's available on the Abbott site.

One part of this animation shows the sensor being worn on the back of the arm. That's a very different location that is currently recommended for CGM sensors.

I'll post more news about the FreeStyle Navigator as I learn about it.

Update: My understanding is that the built-in FreeStyle meter is used to calibrate the Navigator. I do not think they support manual input of the values. I'll try to confirm this and update the page when I learn more.

My new blogging assignment

noreply@blogger.com (Bernard) — Thu, 28 Feb 2008 14:46:00 +0000

I haven't written a blog post for a while due to extreme work pressures. I've had many ideas for a post, but no time to do so.

I received an invitation from David and Elizabeth Edelman of Diabetes Daily to start a blog over there. This seemed like a great opportunity, so I've accepted.

For now, I'll post in both places with different articles and topics. Eventually I'll have to decide how best to handle it.

I'm extremely happy to be joining David, Elizabeth and Amylia on the Diabetes Daily team and I look forward to writing more about diabetes technology and challenges.

Novocell - stem cells control diabetes in mice

noreply@blogger.com (Bernard) — Wed, 20 Feb 2008 20:19:00 +0000

I see this news is being reported in several places. It's interesting because there's been so much talk about using stem cells to treat diabetes. Now Novocell says that they were able to use human stem cells to control diabetes in mice.

Now before you say anything, I do know that things which work for mice don't always work for humans(PDF). But unfortunately most of this research does use NOD (Non obese diabetic) mice, so we're stuck with that for the present.

This approach is not yet perfect because some of the mice developed tumors. I'm guessing that we won't see anything come out of these labs for several years.

Focusing on the numbers

noreply@blogger.com (Bernard) — Wed, 13 Feb 2008 17:01:00 +0000

Recently I put together a table for my endo. It showed how my blood glucose numbers had changed month to month since I started using the Dexcom. I was able to use the Dexcom software to get this information, based on its readings.

I wanted to show it here for a few reasons. (And apologies to anyone who is vision impaired. Blogger does a lousy job with tables, so I had to post a screen snapshot of this.)

First of all, my average (Mean column) is improving most months.

My standard deviation (SD column) is also improving. Here standard deviation indicates how tight my control is. It is now more accepted that tight control may mean less complications. If I can keep my standard deviation to about one-third of my average value, then my control is tight. And I'm nearly there.

In the last column I've shown my A1C values. Again there's improvement there, but not as much as the averages would predict. A blood glucose value of 135 mg/dL should give me an A1C of about 6.0%.

This is why I believe the Dexcom readings are lower than my true blood glucose values. And I blame that on the meter it's being calibrated against. Hence my impatience for the new Dexcom model.

It still amazes me how much those of us with diabetes focus on numbers. It's not like we have a choice. We test several times a day and then do some calculation with the numbers to decide how to correct (carbs or insulin). We try to guesstimate the amount of carbs in the food we're eating and how much insulin we need to cover this. We're constantly calculating to try and be substitute pancreases.

I look forward to the day when we're no longer forced to be math geniuses.

An antidote for diabetes

noreply@blogger.com (Bernard) — Tue, 12 Feb 2008 22:36:00 +0000

Birdie Loo has an inspirational post on her blog Aiming for Grace about looking for an antidote.

I like the idea of offsetting all the physical pain of diabetes with something that's enjoyable. What would I like to do? Just right now, I'm stuck for ideas.

I'll have to do some thinking.

Meeting Dr. Faustman

noreply@blogger.com (Bernard) — Sun, 10 Feb 2008 05:15:00 +0000

In early January I visited the Mass General Hospital research lab where Dr. Denise Faustman is leading research into a possible cure for type 1 diabetes. I was there to give a blood sample for use in this research.

If you've ever met someone you've admired for a while, or maybe a rock or movie star, then you'll know how I felt as I spent time with her.

Over the last two years I've taken part in two bike rides to raise funds for this research. But now I had a chance to actually help support the research in a more direct way.

The lab is drawing samples of blood from people with type 1 diabetes, and 'healthy' volunteers. Because they're having trouble getting healthy volunteers, they ask everyone with diabetes to bring a volunteer with them. These folks must not be directly related to you, and not have any auto-immune diseases. I was fortunate that a friend of mine from work kindly offered to come with me. Paul is one of the founders of the yard sale search site GoYarding.com.

I met Dr. Faustman early in the morning. They do all the sample collection early in the morning so it doesn't interfere with work and school schedules. While we talked, she collected four test tubes of blood from me. She explained that some of this blood was tested using machinery they're developing and some was tested manually by one of the researchers. I believe that manual testing takes about one day to complete.

They're trying to accurately measure the amount of T cells that I have. Her theory is that these T cells are responsible for destroying my insulin producing beta cells. These cells also produce amylin. This is now available as an injectable drug called Symlin that I've written about several times.

You can see a short video of Dr. Faustman and an animation of how they believe the T cell process works on the Iacocca Foundation website.

Some of the blood is also sent to another research lab. They have a method for measuring autoantibodies in blood. She explained that autoantibodies are produced when beta cells are destroyed. So if these were found in my blood, that would indicate that my body had recently lost some beta cells. Which would mean that my body is still making beta cells, 35 years after I first got diabetes.

She hopes to start trials before too long where they will be administering low doses of BCG to see if this can destroy these T cells. BCG is used in Europe as an inoculation against tuberculosis, and is also used as an immunotherapy treatment for bladder cancer.

BCG has been around for a long time. As it's already approved for use as a medical treatment, it is likely that getting approval to use this for other purposes will be quicker and easier than for a new drug. It will probably also be less expensive.

Dr. Faustman's hope was that the FDA would permit trials with low number of subjects. This makes it easier to administer the trials because getting enough people is always a challenge and testing the outcomes is easier with smaller numbers.

She explained that there will likely be several trials with increasing doses, so they can determine if it works, and at what dosage levels. Clearly having automated measurement machinery will make this process a lot faster. They've been working on developing this machinery over the last few years.

I told her that it would be wonderful if they started a blog, even a low-volume one to keep everyone informed about their progress. But she's concerned that will take away from research time and also that the blog may draw a lot of comments that would need to be read and handled.

I imagine the entire lab must feel a little like Banting and Best after insulin was first discovered. They had hundreds of parents from around the world contacting them to try and get their children treated. And that was in the days before the internet and e-mail.

It was a real pleasure spending some time with Dr. Faustman and getting an update on their progress.

I have another appointment in September to get another blood draw. As Dr. Faustman pointed out, this is an easy way to get the latest news. And by then I hope to have completed another bike ride to support her exciting research. I can't wait!

ADA web site takes step backwards - Correction

noreply@blogger.com (Bernard) — Thu, 07 Feb 2008 17:58:00 +0000

After I published the post below, I received comments from several people that they were able to read the ADA web site using Firefox. I checked the site using Firefox on other PCs and they all worked successfully.

So I apologize to the ADA and my readers for not being more careful in checking my facts before blogging about it. That was sloppy of me and I'll be more fastidious before I make an accusation again.

Original post follows:
You've probably seen the news reports about the sudden cancellation of the ACCORD trial. And I'll post about that separately.

I read an e-mail from the American Diabetes Association about this news and it invited me to see the ADA statement about this issue. So I clicked and found the Page Not Found page at the ADA site.

That didn't make sense, I clicked on link in the left-hand menu and was again taken to the Page Not Found page. When I opened the same pages in Internet Explorer the contents are displayed correctly. But if I try this with the Mozilla Firefox browser, none of them display. Which is difficult, because Firefox is the browser I prefer to use.

According to one site, Firefox is used by about 17% of the people browsing the web. That's a lot of folks looking for diabetes information that can't get to it on the ADA site.

To me seems like a step backwards in reaching out to people. Come on ADA, how about supporting all major browsers, not just the one from Microsoft?

Intensive blood sugar control - dangerous in type 2 diabetes?

noreply@blogger.com (Bernard) — Thu, 07 Feb 2008 03:34:00 +0000

You may have seen the news about changes in the ACCORD Trial. This is a clinical study of adults with type 2 diabetes who are at a higher risk for cardiovascular disease.

Some of the people in the trial were following an intensive approach to managing their blood sugar. The aim was to keep their A1C results below 6%. Others in the trial were following a 'standard treatment' with a target A1C between 7% and 7.9%. This second range is much closer to what most people with type 2 diabetes achieve.

Over 10,00 people were taking part in the trial. Over about a four year period 257 people in the intensive group died, compared to 203 people in the standard treatment group. This was equivalent to 3 additional deaths per 1,000 participants per year. And both of these death rates were lower than similar populations in other studies.

About half of the additional deaths were due to cardiovascular disease, the rest were from other issues such as cancer. But it's not clear why these happened.

Because of safety concerns about this increase, the NHLBI who sponsors the trial has decided to stop using the intensive treatment approach and have all participants use the standard one with it's less demanding A1C goals.

If you want more information about the trial and what has changed, the NHLBI has an excellent FAQ page.

And remember, if you have type 1 diabetes, these findings don't apply to you. You should still aim for the best blood glucose control you can safely achieve.

Update: Kelly Close of Close Concerns has a good blog post about this trial, it's also worth reading.

The ACCORD Trial has its own web site, which gives more details about what the study was attempting to find out. From this page you can see that 5,128 people were in the intensive blood glucose control group and 5,123 people were in the standard blood glucose control group.

If you'd like to see other coverage of this situation across the diabetes internet, the diabetes search engine returns a lot of interesting hits for "ACCORD trial".

Have you voted in the US Primaries today?

noreply@blogger.com (Bernard) — Tue, 05 Feb 2008 18:51:00 +0000

Today is the presidential primary day for many states in the US. And my good friend Manny has issued a challenge to the presidential candidates. Are they prepared to make funding for research and treatment of diabetes a National Priority.

This may not seem too important if you don't have diabetes. But remember that a recent study(PDF) showed that in 2007 the US spent over $174 billion dealing with diabets.

How much is that? More than was spent in Iraq supporting the military and dealing with situation there. Or about $580 for every person in the US, that's $2,320 for a family of four. For one year's treatment.

If you'd like to make your opinion heard on this, please complete the Diatribe survey about diabetes and its importance.

Oh, and do please vote in the primaries. It's important to make your opinion count.

David Lazarus on living with diabetes

noreply@blogger.com (Bernard) — Sat, 02 Feb 2008 07:29:00 +0000

I just spotted this Marketplace interview with David Lazarus of the Los Angeles Times. He was diagnosed with diabetes in November 2007.

The title of the interview is 'Living with (and paying for) diabetes'. When he was asked about what he's learned about the costs of living with this chronic disease, he answered

They're extensive. In some cases, some diabetics tell me the spend about $10,000 a year on this thing. You're talking about your blood glucose meter, you're talking about the test strips that are required for that (and I do as many as seven to 10 tests a day), but there are other things as well: you've got you're insulin, you've got your needles, you've got the lancets you need to poke your finger -- again 7 to 10 times a day -- and so you have a lot of fixed costs attached to a chronic disease.

He also talks about the $1 per strip cost. Maybe with his focus on publicizing the costs something may happen.

One of these days some company will wake up to the idea that they can provide accurate strips for $0.50 each and capture a big share of the market. I can't wait for that to happen.

First Impressions of the SymlinPen

noreply@blogger.com (Bernard) — Fri, 01 Feb 2008 02:57:00 +0000

I saw my endo today and I was given a sample SymlinPen 60. I've blogged previously about my experiences with Symlin. So in this post I'll just talk about the pen itself.

When I got home I snapped some pictures before using it.

As you can see the pen itself is a little longer and thicker than a large ballpoint. It's an awkward fit in my shirt pocket, only about a half-inch of the clip is actually holding it in place. I'll definitely keep it in my diabetes kit.

I had planned to use the pen at lunchtime. When I opened the box and took the cap off I found...no pen needle in place. That's right, the sample cannot be used immediately. It's like a Christmas toy that has no batteries and all the stores are closed.

Luckily I had some 10-year old pen needles left from when I used an insulin pen, and once I got home I grabbed one of these. It fit perfectly.

The pen has a dial at one end that lets you choose to dispense Symlin in doses of 15, 30, 45, or 60 micrograms (mcg). For comparison, 10 units of insulin is equal to 60 mcg of Symlin. Many people with type 1 diabetes will use 45mcg or less per meal. If you have type 2 diabetes and are taking insulin then the Symlin 120 pen is probably more useful, it will deliver either 60 or 120 mcg.

To start with I attached the pen needle, dialed up a 15 mcg dose, pulled back the end to prime the pen and dispensed the dose into the air. This was to fill the needle. I repeated this several times until I saw a stream of Symlin.

Then I dialed up my regular dose of 60 mcg and was able to inject it using the wonderfully small pen needle. If you put the needle cover back on, you can replace the pen cap with the needle still in place.

There's an interesting design feature, where you can stand the pen on end. I'm not sure what the benefit of this is, or whether it's just a side-effect of having a built-in plunger.

There are markings on the barrel of the plunger that help you determine whether it's pulled back far enough. This is especially useful when the cartridge is almost empty and there may not be enough Symlin left for the dose you want.

Note that once you've pulled back the plunger the only way to undo this is to dispense the dose. If you dial up too small a dose you can choose a larger number and pull the plunger further back. If you've dialed up too much, you need to just dispense the Symlin into the air.

As you push the plunger there are soft clicking noises. I didn't count these, but there seems to be one click for a 15 mcg dose and three or four (I didn't count carefully enough) for a 60 mcg dose.

Once you've started to use the pen, you can store it at room temperature up to 86 degrees F (30 degrees C). Unopened pens must be stored in a fridge.

Overall I think this is going to be a lot easier than carrying around a vial and syringe. I wish the pens themselves weren't disposable, but that seems to be the way these things are made nowadays. I think I'd give the pen design a score of 7 out of 10.

To improve the score Amylin would need to include a pen needle with their samples and reduce the size enough for this to fit in a normal shirt pocket.
I think this will be a useful addition to my diabetes kit.

Update: As I've used the pen I've paid more attention to how it works.

When you press the 'plunger' to deliver there is one click for every 15 mcg. One each click 15 mcg is actually delivered, so it's a chunky delivery. Because of the pH of Symlin (4.0 which makes it acidic), that first click stings a little. After it stops clicking the plunger still has a way to go, but the last part doesn't deliver anything.

Also, when you dial up a quantity and start to pull back the plunger it clicks, again one click for every 15 mcg. If you pull slowly you can count the clicks. This is probably helpful for anyone who has vision problems. Nice design feature Amylin!

Is this a better way to treat diabetes?

noreply@blogger.com (Bernard) — Mon, 28 Jan 2008 02:08:00 +0000

I was reading Forbes magazine this evening and noticed a full right-page advertisement that started with this statement.

3rd Law of Healthonomics
Soaring healthcare costs are only the symptoms. You've got to start treating the disease.

The remainder of the advertisement reads.

Most employers are rethinking their responses to escalating healthcare costs. Why? They recognize chronic diseases are the root problem. Example: An employee managing his diabetes might cost $5,000 per year. An employee not managing his diabetes could cost up to $45,000. The win-win here is that by providing employees incentives to lead healthier lives an helping them to manage their chronic diseases, you reduce your healthcare costs. And you'll have healthier employees. Sure beaths the alternative.

The advertisement points to a website to 'learn about lowering costs'. That site leads to the Diabetes Ten City Challenge (DTCC) site.

The DTCC FAQ page includes the following summary of how the DTCC works:

The Diabetes Ten City Challenge establishes a voluntary health benefit for employees, dependents and retirees with diabetes, provides incentives through waived co-pays for diabetes medications and supplies, and helps people manage their diabetes with help from a pharmacist coach in collaboration with their physicians and diabetes educators.

I like the idea of waiving co-pays for meds and supplies to help with better diabetes management. I just wonder whether this program is aimed at people with all forms of diabetes, or just those with type 2? Given that one of the sponsors is GlaxoSmithKline, I'll bet I'm right. Will is lead to better benefits for insulin pumps and continuous glucose monitors, or will the focus on cost reduction mean these important technologies are less covered?

This program is being tried by a number of employers in the following cities: Charleston/Spartanburg; Cumberland; Chicago; Colorado Springs; Dalton; Honolulu; Los Angeles; Milwaukee; Pittsburgh; and Tampa Bay.

Have you been enrolled in this program and can you give any feedback on how it works for you? I'm interested in seeing if this is the start of a new approach to diabetes care across the country. And I'd love to know whether or not it includes all types of diabetes.

Walking barefoot

noreply@blogger.com (Bernard) — Fri, 25 Jan 2008 15:53:00 +0000

If you've got diabetes you already know that one of the big challenges is loss of feeling in your feet. This is caused by peripheral neuropathy and it often leads to foot damage because you can't feel the pain of an injury to your feet.

So those of us with diabetes are taught early and often to protect our feet. "Don't walk barefoot" is a standard mantra.

Today I was doing my random walk through the internet and I came across a product called Vibram FiveFingers. I've not bought a pair and I have no connection to the company.

These things look very interesting to me. And the thought of having a barefoot experience of sorts is intriguing. I really like the look of these, someone has clearly put some thought into the design (diabetes product makers take note).

I'm blessed with wide feet, but according to the FiveFinger FAQ (I had to use this alliteration it was too tempting) the material accommodates wide feet. So that removes one obstacle for me.

Have you ever heard of, or bought a pair of these? I'm tempted, but at $70 and more for a pair I'd love to know before I invest in them.