2013-03-05

Diabetics Are Better-Treated In The United States

Follow The Correct Prognosis
Because my blood sugar readings always trended high in the afternoon, I once asked my Canadian endocrinology team whether it would be a good idea to split my once-a-day Lantus dose into two doses per day. The response was an emphatic "No!" but the explanation was highly ambiguous. The team told me that there were "problems" with doing this, and an increased danger of hypoglycemia. One of them insisted that, because I work out in the afternoons, trending high was basically a good thing because it was preventing me from going low during exercise.

I was a new diabetic. I took their advice at face-value. They were experts, not me. Nevertheless, as the years went by, it became progressively more obvious that a once-daily dose of Lantus wasn't staying in my body for the full 24 hours. When I talked to my Canadian team about this, they readily acknowledged that Lantus' efficacy starts to wane at about twenty hours, give or take. Their solution? I should take my 24-hour dose earlier in the day.

Think about that. Their position was that, because Lantus was only effective for about 20 hours, I should take my dose at 9:00pm instead of 10:00pm. If you're not exactly sure how that helps cover the missing four hours, you're not alone. But the goal of Canadian health care practitioners seems to be getting the patient to stop asking questions and just adhere to their prognosis. I was young, naive, and the tactic worked on me. I am ashamed to say so, but it's true.

Fast-forward to my return to the United States, a decision I made in part to receive better treatment for my diabetes. My US team took one look at my blood sugar pattern and immediately labeled me "an uncontrolled diabetic." I didn't like hearing that, but sometimes it's more important to take care of the body than it is to take care of the ego.

But here's where it gets interesting. The recommendation of my US team was... Split my Lantus dose and take it twice a day! The exact opposite of the Canadian recommendation. When I told my US endocrinologist that the Canadian doctors told me not to do this, she said (in her slightly curt, and politely dismissive way), "Really? We do it all the time." And that was the end of the discussion.

Taking my US doctor's advice, I am now taking Lantus twice a day, and the results are excellent. My blood sugar is in much better control and I feel great. For those of you (type 1 diabetics) considering a twice-daily regimen for your long-acting insulin, I highly recommend it. I can also assure you that there is no "transition period" to worry about. You simply take half your dose, as usual, and then take the other half 12 hours later. Your body doesn't "feel any different" as you make the switch, except insofar as your blood sugar stabilizes.

What's important here is the fact that the Canadian team considered the correct prognosis to be medically dangerous, despite the fact that it is not at all medically dangerous. It is the correct prognosis. I could never have hoped to achieve blood glucose control in Canada so long as I was being advised against following the correct insulin regimen!

But Why Would They Do That?
Now for a little background on why the Canadian team was giving me such bad advice...

Lantus was a major pharmaceutical breakthrough. This product is insulin suspended in crystals. When you inject Lantus, the crystals slowly dissolve over a very long time period, releasing a steady flow of insulin into the blood stream over that time period. In order to demonstrate just how innovative this product is, the manufacturer produced studies and data showing that large quantities of Lantus could remain active in the blood stream for a full 24 hours. As a result of this data, Lantus was approved by the world's various health regulatory agencies as a "twenty-four hour insulin."

Left out of the story, though, was the fact that smaller amounts of Lantus do not remain active in the blood stream for a full twenty-four hour time period. That means type 2 diabetics can enjoy an enormous Lantus injection that lasts 24 hours, but type 1 diabetics who use Lantus find themselves running short of long-acting insulin late in the day. To reap the same kind of benefits Lantus confers on type 2 diabetics, we type 1 diabetics need to inject a smaller amount of insulin, and do so twice per day instead of once.

Using Lantus twice-a-day, though, runs contrary to the regulatory approval Lantus initially received. Basically, because the manufacturer demonstrated 24-hour efficacy, Lantus received approval for once-daily injections, despite the fact that there are other ways to use Lantus. But, to the regulators, the only way to use a product is the way they approve it to be used. Period, end of story.

In the United States, this fact is not very important, because doctors aren't (yet) owned, controlled, and paid by the government. So doctors can simply prescribe the correct dosing regimen, and to hell with what the bureaucrats have "approved." You need Lantus twice a day? You get Lantus twice a day, because that's what works.

But, in Canada, the doctors are completely owned and controlled by the government. To put it succinctly, if a Canadian doctor tells a patient to do something other than what the regulators have "approved," then that doctor has some 'splainin' to do. And no bureaucrat likes having to explain themselves, therefore the only Lantus regimen that can possibly exist in the Canadian universe is the once-daily regimen. Period. Anything else means medical tribunals and heavy-handed regulatory blowback.

Epilogue
One final footnote on this. Yesterday, my US endocrinologist asked me how I approach negative corrections. "Negative corrections?" I asked. "Yes," she said, "do you know about negative corrections?" I told her I had never before heard of them.

She quickly produced a chart of dosing corrections based on blood glucose readings. When your blood sugar tests high at mealtimes, you are supposed to take extra mealtime insulin in order to bring it back under control. That's a "positive correction." A "negative correction" is when you reduce your mealtime bolus based on a blood glucose reading lower than the benchmark. Negative corrections even apply when you are not in a state of hypoglycemia. It's just another level of fine-tuning one's insulin dose.

But it is a level of fine-tuning that my Canadian team never told me about. Add this to the ever-growing list of reasons why the US health care system will always be better than the Canadian system, despite what Paul Krugman and the liberals tell you. You can't take a New York Times op-ed to the bank. Blood glucose readings are something you can.