Approved Help out a Trainee Pharmacist?

[BluePharma]

My name is Tim and I am a Pre-registration (trainee) Pharmacist working/studying in a hospital under the NHS. I've been given the task of delivering a small presentation to some trainee Pharmacy technicians. These are the lovely people who you'll likely meet in a hospital setting who will ask you about your medication so we have an up to date record of what you take and how you take it. They aren't as knowledgeable about medicines as a Pharmacist but they are a key part of the team who will need to communicate to inpatients about their drugs on a daily basis.

As well as going over the basics of blood glucose, insulin and medication related to diabetes I'd love to give the technicians some examples or 'case studies' of people who have diabetes and their experiences. I came across this forum while studying diabetes in University - it struck me as a brilliant means for people with diabetes to communicate and share advice with one another but also for future healthcare professionals such as myself to gain a better understanding of our diabetic patients.

So, I'd be very grateful if anyone could answer any or all of the below questions - I'm not looking for lots in the way of detail but I am really interested in YOUR individual experience.

I'd like to hear a summary of what diabetic medication you take, when you take it, how you take it (please also state if you're type 1, type 2...). I'd also like to know about the reasons you take the medications the way you do - particularly things that are unique to you. Were you put off a certain drug because of its side effects? Another example may be altering the times you take insulin to deal with working a night shift or using a modified release metformin to ease the side effects.

What changes to your medication have been made over time to improve your experience with diabetes and your control? Some examples: Has a switch to a longer acting insulin made it easier to fit injections into your daily life? Has a switch to a more frequent, shorter acting insulin given you better control?

Do you test your blood glucose - if so, how and how often?

How does a hypo feel? What do you do to deal with a hypo?

If you have any experience with Pharmacy technicians in a hospital - what did you think? What did they do well, what did they do that wasn't so good?

If there's anything else you think is relevant, I'd be keen to hear about it.

Apologies for the length of this post. Thanks to everyone who sticks through it and especially to those who take the time to reply. I really appreciate it and I'm sure the technicians will too!

 

[TorqPenderloin]

I think my situation may be of interest to you.

I found out earlier this month I was type 1.
Prior to diagnosis, I was prescribed Prednisone for a rash on my back. While I don't believe the Prednisone (by itself) caused my diabetes, several doctors believe it was what "unveiled" my diabetes at 27 years old. Prednisone is an oral steroid known to significantly increase blood sugar levels....for me, it raised them high enough to put me in the ER (500+)

This may sound silly, but to me, a hypo feels a lot like (I assume) a drug withdrawal. I haven't had a severe hypo yet, but when my levels get below 70 I start to get pretty bad shakes, clammy hands (and extremedies), and I get w bit antsy (perhaps from worrying).

Four weeks into my diagnosis and I'm already on a Dexcom G5. It's a CGM and the most recent system from Dexcom that sends my blood sugar levels directly to my iPhone via a Bluetooth connection. The sensor is placed just to the left of my bully button.

To calibrate my dexcom, I still need to perform traditional finger prick tests. I have a One Touch Ultra2 and a One Touch UltraMini. I take readings from each meter and average them together and enter that into my dexcom.

For me, information is most important at this point. It was worth it to invest in the Dexcom but I have no desire to own an insulin pump yet. I take Levemir extended release insulin twice a day. With my (heavy) exercise levels and eating 6-7 smaller meals/day, I only need meal time insulin at dinner (I burn enough carbs during my workouts to not need it at breakfast and lunch).

Hope this helps. If you're still interest in the Prednisone situation, let me know. That seems to be the most "unique" part of my situation.
-Mark

 

[BluePharma]

I think my situation may be of interest to you.

I found out earlier this month I was type 1.
Prior to diagnosis, I was prescribed Prednisone for a rash on my back. While I don't believe the Prednisone (by itself) caused my diabetes, several doctors believe it was what "unveiled" my diabetes at 27 years old. Prednisone is an oral steroid known to significantly increase blood sugar levels....for me, it raised them high enough to put me in the ER (500+)

This may sound silly, but to me, a hypo feels a lot like (I assume) a drug withdrawal. I haven't had a severe hypo yet, but when my levels get below 70 I start to get pretty bad shakes, clammy hands (and extremedies), and I get w bit antsy (perhaps from worrying).

Four weeks into my diagnosis and I'm already on a Dexcom G5. It's a CGM and the most recent system from Dexcom that sends my blood sugar levels directly to my iPhone via a Bluetooth connection. The sensor is placed just to the left of my bully button.

To calibrate my dexcom, I still need to perform traditional finger prick tests. I have a One Touch Ultra2 and a One Touch UltraMini. I take readings from each meter and average them together and enter that into my dexcom.

For me, information is most important at this point. It was worth it to invest in the Dexcom but I have no desire to own an insulin pump yet. I take Levemir extended release insulin twice a day. With my (heavy) exercise levels and eating 6-7 smaller meals/day, I only need meal time insulin at dinner (I burn enough carbs during my workouts to not need it at breakfast and lunch).

Hope this helps. If you're still interest in the Prednisone situation, let me know. That seems to be the most "unique" part of my situation.
-Mark

This is exactly the kind of thing I was looking for! Thanks for taking the time to read and reply. Could you clarify what you mean by meal time insulin? I'm assuming this is a short acting preparation - I'd like to be able to quote a specific brand if possible. If you could also tell me how many units of each you take, that would be great.

Thanks again!

 

[phoenix]

I was first diagnosed with T1 (well it could be 1.5 said the doctor) in 2004 at the age of 52 (quite a shock) Initially,I used Novorapid and Lantus. I was prescribed a fixed amount of carbs per day and taught to use a sliding scale.http://dtc.ucsf.edu/types-of-diabet...pies/type-2-insulin-rx/sliding-scale-therapy/
This was horribly restrictive .It worked OK but because it was reactive , it meant that everything had to be totally pre planned. I had to eat the right amount of carbs and exercise at the same time. The first Christmas after my diagnosis I stayed at home refusing to visit family because of the limitations imposed by this regime.
Fortunately, through online forums, and internet sites I learned to adjust my dose to suit my activity levels and to be able to vary my meals. This meant I had control for myself.(rather than the regimen controlling me) See for example http://www.bdec-e-learning.com/ ( I didn't use that but it shows what I did)
However, I became more more active as I trained for a marathon and I found I was hypo a lot of the time (I could always treat it but I was recognising the hypos at lower and lower levels). The problem was with the basal insulin, I almost didn't need any when exercising. I had an HbA1c of 4.9% when my doctor advised using a pump since the basal could be adjusted at will.
I've been using the pump for over 7 years now. I use Apidra in it (I've no idea why the doctor changed from Novo to Apidra; maybe because it's supposed to be a bit faster, but just maybe because it was newly on the market and,it's a French make. I live in France and get the impression that there is a selective bias towards drugs from French companies)
I had a 4 day course as an in patient to learn to use the pump. Nevertheless, online help was invaluable, as was the book Pumping Insulin by John Walsh (known as the pumpers 'bible)
I still love the flexibility of the pump. I don't run anymore but I still hillwalk and can turn my basal down to a miniscule amount. Without it I would be having to take glucose tablets or stopping to eat when I don't want to.

I used to test at least 6 times a day, now it's less with a minimum of 4. I also have a Freestyle Libre which I use for continuous monitoring every so often (the sensors are too expensive for me to use on a regular basis and I probably have good enough control without it. For me, it is invaluable for holidays, illness ie times when I'm doing different things and eating differently.

Hypos vary, my first involved lots of shaking and pouring sweat.
The signs are more subtle now, lack of energy, fuzzy headedness, feeling that I don't want to communicate with the world. Sweating still happens but is not an effective sign since I also sweat with normal glucose levels when exercising .When I was going through the menopause, night sweats could be due to that or to a hypo.

I did have a period just under two years ago when my cholesterol went up, I became lethargic and put on weight . Blood tests found autoimmune hypothyroid and I now take levothyroxine. When it was balanced (at the moment at 87.5 mcg), cholesterol went back down, weight went down albeit with a bit of effort .
I also take 150mg Aprovel 'to protect kidneys' , there has never been any protein in my urine though and myEgfr is OK. My BP is also fine (well when I wear a continuous monitor, not when the doc tests!)

 

[BluePharma]

I was first diagnosed with T1 (well it could be 1.5 said the doctor) in 2004 at the age of 52 (quite a shock) Initially,I used Novorapid and Lantus. I was prescribed a fixed amount of carbs per day and taught to use a sliding scale.http://dtc.ucsf.edu/types-of-diabet...pies/type-2-insulin-rx/sliding-scale-therapy/
This was horribly restrictive .It worked OK but because it was reactive , it meant that everything had to be totally pre planned. I had to eat the right amount of carbs and exercise at the same time. The first Christmas after my diagnosis I stayed at home refusing to visit family because of the limitations imposed by this regime.
Fortunately, through online forums, and internet sites I learned to adjust my dose to suit my activity levels and to be able to vary my meals. This meant I had control for myself.(rather than the regimen controlling me) See for example http://www.bdec-e-learning.com/ ( I didn't use that but it shows what I did)
However, I became more more active as I trained for a marathon and I found I was hypo a lot of the time (I could always treat it but I was recognising the hypos at lower and lower levels). The problem was with the basal insulin, I almost didn't need any when exercising. I had an HbA1c of 4.9% when my doctor advised using a pump since the basal could be adjusted at will.
I've been using the pump for over 7 years now. I use Apidra in it (I've no idea why the doctor changed from Novo to Apidra; maybe because it's supposed to be a bit faster, but just maybe because it was newly on the market and,it's a French make. I live in France and get the impression that there is a selective bias towards drugs from French companies)
I had a 4 day course as an in patient to learn to use the pump. Nevertheless, online help was invaluable, as was the book Pumping Insulin by John Walsh (known as the pumpers 'bible)
I still love the flexibility of the pump. I don't run anymore but I still hillwalk and can turn my basal down to a miniscule amount. Without it I would be having to take glucose tablets or stopping to eat when I don't want to.

I used to test at least 6 times a day, now it's less with a minimum of 4. I also have a Freestyle Libre which I use for continuous monitoring every so often (the sensors are too expensive for me to use on a regular basis and I probably have good enough control without it. For me, it is invaluable for holidays, illness ie times when I'm doing different things and eating differently.

Hypos vary, my first involved lots of shaking and pouring sweat.
The signs are more subtle now, lack of energy, fuzzy headedness, feeling that I don't want to communicate with the world. Sweating still happens but is not an effective sign since I also sweat with normal glucose levels when exercising .When I was going through the menopause, night sweats could be due to that or to a hypo.

I did have a period just under two years ago when my cholesterol went up, I became lethargic and put on weight . Blood tests found autoimmune hypothyroid and I now take levothyroxine. When it was balanced (at the moment at 87.5 mcg), cholesterol went back down, weight went down albeit with a bit of effort .
I also take 150mg Aprovel 'to protect kidneys' , there has never been any protein in my urine though and myEgfr is OK. My BP is also fine (well when I wear a continuous monitor, not when the doc tests!)

Thank you very much, this is great! I do remember reading about the sliding scale regime before but hadn't remembered to include it in my presentation. I'll go and sort that out over my lunch break, cheers!

 

[phoenix]

Thank you very much, this is great! I do remember reading about the sliding scale regime before but hadn't remembered to include it in my presentation. I'll go and sort that out over my lunch break, cheers!

NB sliding scale is often also used to describe intravenous insulin dosing in hospital http://www.icid.salisbury.nhs.uk/Cl...ctiveUseofIntravenousSlidingScaleInsulin.aspx

 

[BluePharma]

NB sliding scale is often also used to describe intravenous insulin dosing in hospital http://www.icid.salisbury.nhs.uk/Cl...ctiveUseofIntravenousSlidingScaleInsulin.aspx

I saw a sliding scale similar to this on the ward the other week. Its particularly relevant to us as we're training in a hospital environment! I'll have to try and get a copy of the one associated with my trust.

 

[TorqPenderloin]

This is exactly the kind of thing I was looking for! Thanks for taking the time to read and reply. Could you clarify what you mean by meal time insulin? I'm assuming this is a short acting preparation - I'd like to be able to quote a specific brand if possible. If you could also tell me how many units of each you take, that would be great.

Thanks again!

Disclaimer: as mentioned I was diagnosed less than four weeks ago so this is the "dumbed down" version:

I'm using Levemir Flextouch pens 14 units twice a day (4am and 6pm). Its absorbed slower but more consistently throughout the day.

I'm also using Humalog for "meal time insulin." Meal time insulin is absorbed much faster (I was told 30% each hour) and it's used to counter the carbohydrates you eat during your meals. Many people elect to maintain a low carb diet, for more reasons than one, so they don't have to inject themselves with insulin 6+ times a day. For me, I control my blood sugar in the morning with exercise. I eat smaller consistent meals throughout the day to avoid taking shots at work, and I give myself a shot 30 minutes before dinner.....well because I like eating a big dinner, lol. Four weeks in and things have been pretty consistent. It's still a learning process, but I've been consistently around 80-110 mg/dl for most of the day with this approach.

 

[Lamont D]

I have a blood glucose disorder called Reactive Hypoglycaemia.

I don't rely on meds!

Have a read of my blog on the condition.

I do take sitagliptin, which helps with my condition, but it is not a cure, remedy or go to med!

 

[BluePharma]

I have a blood glucose disorder called Reactive Hypoglycaemia.

I don't rely on meds!

Have a read of my blog on the condition.

I do take sitagliptin, which helps with my condition, but it is not a cure, remedy or go to med!

While its probably outside the range of what the technicians need to know, I'll be sure to have a read sometime. Thank you!

 

[Lozj82]

Hi i have been a type 1 diabetic since i was 10 months old and over the years have seen many changes (as i'm sure others have aswell). I used to take 2 injections a day and mix insulin (long acting and short acting- velosulin and insulatard) however as i became a teenager and wanted to eat other things than just stick to a diet - which was the problem of mixing insulin - i had to stick to a diet as i had already taken my 'long acting' in the morning to cover my lunch. I then decided to swap from 2 injections a day to 5 (2 long acting (lantus)- some people take 1 long acting a day however we decided that 2 would be better for me, 1 in a morning and 1 at night) and 3 short acting (novorapid) taken every time i eat, this has enabled me to eat different things at different times of the day. The only other medication (if you can call it that) i have taken for diabetes is steroid cream for necrobiosis, however i do take other medications for other conditions and obviously it always needs to be checked to make sure it isnt going to interfere, my hypothyroidism had an effect on my diabetes as i was always tired and wasn't doing as much so had to alter the insulin levels.

A hypo in my opinion feels a bit like low blood pressure in a way but with added extras, you have no energy, you are shaking, sweating, heart racing, blurry vision and if it gets really low (i had a 1.2 just the other week) i felt like i could hardly move to the lack of energy, i take 125ml of juice and test in 15 mins to see if it has risen (or 3 glucotabs).

At the moment i am testing about 8-10 times a day (sometimes more if exercising or hypo or eating a meal i know my sugar spikes with) in order to try and get better control, it seems excessive but its amazing what the difference can in just an hour (from normal e.g 5 to 10 in half an hour), i would love some sort of cgm in order to stop having to prick my fingers so much but it is so expensive.

Hope i have helped in some way

 

[BluePharma]

Hi i have been a type 1 diabetic since i was 10 months old and over the years have seen many changes (as i'm sure others have aswell). I used to take 2 injections a day and mix insulin (long acting and short acting- velosulin and insulatard) however as i became a teenager and wanted to eat other things than just stick to a diet - which was the problem of mixing insulin - i had to stick to a diet as i had already taken my 'long acting' in the morning to cover my lunch. I then decided to swap from 2 injections a day to 5 (2 long acting (lantus)- some people take 1 long acting a day however we decided that 2 would be better for me, 1 in a morning and 1 at night) and 3 short acting (novorapid) taken every time i eat, this has enabled me to eat different things at different times of the day. The only other medication (if you can call it that) i have taken for diabetes is steroid cream for necrobiosis, however i do take other medications for other conditions and obviously it always needs to be checked to make sure it isnt going to interfere, my hypothyroidism had an effect on my diabetes as i was always tired and wasn't doing as much so had to alter the insulin levels.

A hypo in my opinion feels a bit like low blood pressure in a way but with added extras, you have no energy, you are shaking, sweating, heart racing, blurry vision and if it gets really low (i had a 1.2 just the other week) i felt like i could hardly move to the lack of energy, i take 125ml of juice and test in 15 mins to see if it has risen (or 3 glucotabs).

At the moment i am testing about 8-10 times a day (sometimes more if exercising or hypo or eating a meal i know my sugar spikes with) in order to try and get better control, it seems excessive but its amazing what the difference can in just an hour (from normal e.g 5 to 10 in half an hour), i would love some sort of cgm in order to stop having to prick my fingers so much but it is so expensive.

Hope i have helped in some way

Thank you so much! This is great stuff.

Its one thing learning from books and websites about different insulin preparations and how often they should be taken etc but it really puts it into perspective when I see examples like this - with explanations from the people with first hand experience. Thanks again to everyone who has replied so far, I'm sure the technicians will really benefit from your input.

 

[Lamont D]

While its probably outside the range of what the technicians need to know, I'll be sure to have a read sometime. Thank you!

My first response is why is it outside the range? it is an endocrine condition, blood glucose disorder and has shown that the way to treat the condition is by food with a little help with medication. It is an extreme version and rare. But the underlying benefit of knowledge of the condition is that pharmaceuticals are not always necessary in treating diabetes and blood glucose disorders.
Why treat a food disorder with drugs, when food is more than likely the answer.
It is knowledge that, I have been able to decide, not to take statins, even though, I am in the risk factor.
Because of my lifestyle, in other words what I eat has made me healthy and fit.
Not drugs, not the recommended diets, just food.

Have a think about, what I am posting, as the change in peoples perception of what is healthy, May not be the one, whilst you are training!
What you are being taught makes me ill and keeps diabetics dependent on drugs.
Learn the real food that helps diabetics, not what is being trailed out at most of our diabetic clinics and the NHS dieticians.

Knowledge is the key to being healthy.

 

[BluePharma]

My first response is why is it outside the range? it is an endocrine condition, blood glucose disorder and has shown that the way to treat the condition is by food with a little help with medication. It is an extreme version and rare. But the underlying benefit of knowledge of the condition is that pharmaceuticals are not always necessary in treating diabetes and blood glucose disorders.
Why treat a food disorder with drugs, when food is more than likely the answer.
It is knowledge that, I have been able to decide, not to take statins, even though, I am in the risk factor.
Because of my lifestyle, in other words what I eat has made me healthy and fit.
Not drugs, not the recommended diets, just food.

Have a think about, what I am posting, as the change in peoples perception of what is healthy, May not be the one, whilst you are training!
What you are being taught makes me ill and keeps diabetics dependent on drugs.
Learn the real food that helps diabetics, not what is being trailed out at most of our diabetic clinics and the NHS dieticians.

Knowledge is the key to being healthy.

I want to apologise if I came off as a bit dismissive and rude - that wasn't at all my intention. Unfortunately I've got a very limited amount of time to give my talk to the technicians and want to concentrate on the most common things they'll come across.

From what I've read on Reactive Hypoglycemia, you're absolutely right, most people with the condition get on fine without medication. Just so we're on the same page, are you also saying that a type 1 diabetic can cope fine without much or any helps from medication?

 

[Lamont D]

I want to apologise if I came off as a bit dismissive and rude - that wasn't at all my intention. Unfortunately I've got a very limited amount of time to give my talk to the technicians and want to concentrate on the most common things they'll come across.

From what I've read on Reactive Hypoglycemia, you're absolutely right, most people with the condition get on fine without medication. Just so we're on the same page, are you also saying that a type 1 diabetic can cope fine without much or any helps from medication?

That's taking my post out of context.
I don't believe that they can do, but they could use less by eating the right balance.
T1 is not a food or blood glucose disorder. It is autoimmune condition.
T1 & T2,as well as the other diabetic or non diabetic conditions are all different and all of these individuals that have these conditions are different and one size fits all doesn't work.
They have to be treated as individually as possibly, that's, where treatment is so important.
And food is intrinsic in that treatment.
Medication and care is also important in control.
The control of blood glucose levels helps the patient relieve symptoms that can be so important in future health.
Knowledge is so important.

 

[mrspuddleduck]

I'm a type 3c. A brittle form of insulin dependent diabetes, my dosage can vary quite dramatically from day to day and am prone to sudden highs and lows with no (predictable) reason. I'm on humulin in the mornings, and humalog for meals, can't use insulin at night because of the risk of hypos. Just to complicate things I'm also steroid dependant and have exocrine deficiency with mal absorption. Just wanted to throw it in the pot as a reminder that diabetes is more complicated than just type 1 & 2!

 

[BluePharma]

I'm a type 3cc. A brittle form of insulin dependent diabetes, my dosage can vary quite dramatically from day to day and am prone to sudden highs and lows with no (predictable) reason. I'm on humulin in the mornings, and humalog for meals, can't use insulin at night because of the risk of hypos. Just to complicate things I'm also steroid dependant and have exocrine deficiency with mal absorption. Just wanted to throw it in the pot as a reminder that diabetes is more complicated than just type 1 & 2!

Unfortunately while type 3c was briefly mentioned in University I don't know much about it. Thanks for the reminder though. It must be hard to keep an eye on your blood glucose levels. Do you do regular blood glucose strip testing or have an electronic device similar to the first gentleman who replied?

 

[mrspuddleduck]

Unfortunately while type 3c was briefly mentioned in University I don't know much about it. Thanks for the reminder though. It must be hard to keep an eye on your blood glucose levels. Do you do regular blood glucose strip testing or have an electronic device similar to the first gentleman who replied?

I finger test about 8 times a day and once or twice in the night. Sadly I can't afford cgm or libre and my health trust doesn't fund them Oh and just for interest Im only allowed 100 test strips and lancets on prescription every two months ,yep do the maths!!

 

[BluePharma]

That's taking my post out of context.
I don't believe that they can do, but they could use less by eating the right balance.
T1 is not a food or blood glucose disorder. It is autoimmune condition.
T1 & T2,as well as the other diabetic or non diabetic conditions are all different and all of these individuals that have these conditions are different and one size fits all doesn't work.
They have to be treated as individually as possibly, that's, where treatment is so important.
And food is intrinsic in that treatment.
Medication and care is also important in control.
The control of blood glucose levels helps the patient relieve symptoms that can be so important in future health.
Knowledge is so important.

Can you summarise what sort of balance of food you mean? University taught me that where possible lifestyle alterations such as food and exercise should be advised before resorting to a drug. Things that I learned about were the "eatwell plate" and basics like trying to get your five fruit and veg a day.

 

[Lamont D]

Can you summarise what sort of balance of food you mean? University taught me that where possible lifestyle alterations such as food and exercise should be advised before resorting to a drug. Things that I learned about were the "eatwell plate" and basics like trying to get your five fruit and veg a day.

I would like to start by saying that the recommended 'eatwell plate' had me gaining weight and totally out of control of my blood glucose levels. It was making me ill.
The five a day vegetables, five fruits are fine for a healthy person but for diabetics and like myself there is too much fructose(sugars) starch(sugar) that have an adverse effect on blood glucose levels. It is carbs and sugar that raises levels.
As a RH patient, I am practically allergic to carbs and sugars.
So my lifestyle, not a diet, because it's for my lifetime. I have to eat protein and salad vegetables, the odd pulses, and I eat full fat food because low fat or reduced or no fat contains hidden sugars. I try to avoid processed foods and produced foods, because again of the hidden manufacturing sugars.
I have to be careful what I digest and what I drink. I can only have tea, black, no sugar (of course) water which is ready important and a diet drink now and then. Salt replacement is important and not to be avoided.
I eat plenty of eggs, they are a vital source of vitamins.
Berries are ok, as are apples, pears in small pieces, but most fruit has too many carbs.

I am permanently in ketosis. Look it up.

I eat what is known as LCHF! Low carb, high fat!
It is the opposite of what you are being told to recommend.
Yours made me ill, because of the high carb 'reactive' effects.
Mine works because it doesn't! I am permanently in the zone of normal blood glucose levels!

Food for thought! (Sorry about the pun!)

Oh yeah! I am a pensioner who could give you a run for your money. I work manually full time, and run and train a youth football team. I have never felt fitter and healthier since I was a twenty year old!