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Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S adults.
Rationale for the use of insulin therapy alone as the pharmacological treatment of type 2 diabetes.
A study of the effects of hypoglycemic agents on vascular complications in patients with adult-onset diabetes. Easy-to-use postcard size resource that summarizes the classes and main actions of oral diabetes medications.
Easy-to-use postcard size resource that summarizes the timing and types of insulin and injectables. Have access to our popular diabetes Medication PocketCards, study tools for the CDE® Exam, plus critical resources that improve patient care.  Enjoy instant access to on-demand webinars, articles, newsletters, books and study tools in the palm of your hand! This App was designed by CDE® Coach, Beverly Thomassian, RN, MPH, CDE®, BC-ADM, a nationally recognized diabetes expert and working educator, who has passed her CDE® Exam five times. Tired of searching for resources?  Ready to take your diabetes clinical care to the next level? Footer Left DescriptionDiabetes Education Services offers education and training to diabetes educators in the areas of both Type 1 and Type 2 Diabetes for the novice to the established professional.
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Your blood sugar may be too high because of excess carbohydrate (sugar and starch) in the diet the wrong insulin dose illness stress inactivity frequent Diet Cuts Diabetes Risk Without Calorie Restrictions Researchers tested the efficacy of a Mediterranean diet enriched with extra-virgin olive oil Foot Ulcer A 67-year-old woman with insulin-dependent diabetes mellitus and uncontrolled hyperglycemia complained of fatigue and malaise. The pump unit contains a small syringe reservoir filled with short-acting Avoiding Gestational Diabetes Second Pregnancy Flashing Eyes insulin an electromechanical assembly that advances the syringe plunger and a microprocessor.
Diabetes India – Diet Charts Diabetes has reached serious proportions and accounts for around 5% of the population of India. A person with certain risk factors is more likely to develop prediabetes and type 2 diabetes. Invokana is a medication that decreases blood glucose (sugar) in people with diabetes by blocking the kidney from reabsorbing glucose and removing excess glucose through the urine.
Invokana is a prescription medicine used along with diet and exercise to lower blood sugar in adults with Type-2 diabetes.
Invokana’s efficacy is dependent on the filtration capacity of kidneys also known as glomerular filtration rate (GFR). Invokana 100 and 300 mg once daily were evaluated as monotherapy and as add-on to other anti-diabetic agents.
A 52-week, double-blind study enrolled 1,450 patients with type 2 diabetes who were inadequately controlled on metformin monotherapy. Invokana was compared to sitagliptin, both as an add-on combination therapy with metformin and sulfonylurea in 52-week, double-blind, active-controlled study which enrolled 755 patients with type 2 diabetes inadequately controlled on metformin and sulfonylurea.
Invokana is the first diabetes treatment approved in a new class of drugs known as sodium-glucose co-transporter 2 (SGLT2)inhibitors. Common side effects of Invokana are yeast infections, urinary tract infections, and increased urination. For obtaining prescription assistance and Invokana Savings Card adn Coupon visit Invokana Care Path.
The content on this website is for information only and is not a substitute for professional medical advice, diagnosis, and treatment. Recent studies suggest that Medicaid expansion will result in health and financial gains.  Older studies also found salutary health effects of expanded or improved insurance coverage, particularly for lower income adults.
The Supreme Court ruled in June 2012 that states may opt out of Medicaid expansion, and as of November 2013, 25 states have done so.
In this post, we estimate the number and demographic characteristics of people likely to remain uninsured as a result of states’ opting out of Medicaid expansion.
The Supreme Court’s decision to allow states to opt out of Medicaid expansion will have adverse health and financial consequences. Despite the widely held belief that almost all Americans will be insured under the ACA, more than 32 million people will remain uninsured after the law goes into effect. Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage. Predicted national-level consequences of states opting out of Medicaid expansion are displayed in Exhibit 2. State-level estimates for post-ACA effects of opting out of Medicaid expansion are displayed in Exhibit 3.
We categorized states as opting in or opting out of Medicaid expansion using the Kaiser Family Foundation’s “Status of State Action on the Medicaid Expansion Decision,” which was updated on November 22, 2013. The patients studied in the OHIE were slightly older than the uninsured poor in opt-out states, and more often female.  While we were able to adjust for these demographic differences in estimating cancer screening rates, it was not possible to do so for other effects. Your map has Vermont as one of the states that opted out , yet your exhibit #1 Table shows Vermont as one of the states that opted in ? No one doubts Medicaid (actual value=99%) is better for family finances than employer-based health coverage (actual value~80%). The AJPH finding of a 40% increase in mortality risk associated with being uninsured is by far the highest in the literature that has directly tried to calculate this value. It’s difficult to believe that the differences in physical health measurement between the Kronick study and AJPH study would account for a 40 percent mortality hazard disappearing. I stand by my belief that the authors have grossly overestimated potential mortality gains associated with Medicaid expansion. Michael Bertaut brings up valid concerns about needed financing increases to the Medicaid program, though this was not the focus of our post. One should also note that states opting for the Medicaid expansion receive a large influx of federal funds that would reduce hospitals’ uncompensated care and serve as an economic stimulus. Professor Conover questions the generalizability of the Wilper AJPH study to Medicaid patients. Professor Conover notes that in the Sommers study, the observed decline in mortality in Arizona did not achieve statistical significance. As a physician who has taken care of thousands of Medicaid patients in my 35 year medical career, I am acutely aware of the problems we face caring for these people.
The second study used to generate the lower bound mortality figure (7,115) is based on Himmelstein and Woolhandler’s own previous work in AJPH.
That the authors should bypass a much stronger study showing no mortality benefit from private insurance in favor of a weaker study appearing to show a 40% mortality risk associated with being uninsured is a bit disturbing.
These authors should be well aware that just the act of adding signficant numbers of people, in some states increasing Medicaid populations by 50% or more, will require a heavy investment up-front of state revenue to enact. I am a just retired(at age 80) physician who completed 28 years of volunteering in free clinics staffed by volunteers and providing comprehensive care to the working poor who were not Medicaid eligible. I now realize that there will be serious shortcomings in some of the states including South Carolina. South Carolina’s decision to opt out of Medicaid expansion may have adverse health and financial consequences.
This continues to pose a real challenge to physicians as the prevalence of this disease in the United States continues to rise. The focus of this review will be the management of patients with type 2 diabetes using one or more of the five available classes of oral hypoglycemic agents: sulfonylureas, meglitinides, biguanides, thiazolidinediones and alphaglucosidase inhibitors (Table 1). Metformin (Glucophage) is currently the only agent in this antidiabetic class available in this country. Food and Drug Administration (FDA) included troglitazone (Rezulin), rosiglitazone (Avandia) and pioglitazone (Actos). Alpha-glucosidase inhibitors act by inhibiting the enzyme alpha-glucosidase found in the brush border cells that line the small intestine, which cleaves more complex carbohydrates into sugars. Reasonable combinations of agents include a sulfonylurea plus metformin, a sulfonylurea plus an alpha-glucosidase inhibitor, a sulfonylurea plus a thiazolidinedione, metformin plus repaglinide, biguanide plus alpha-glucosidase inhibitor, and metformin plus a thiazolidinedione.
Concise and user-friendly.  A complete listing of the classes, action, dose range and considerations for all the currently available oral diabetes agents. The oral medication card summarizes the classes, main actions, dosing and side effects of oral diabetes medications.
Coach Thomassian has helped hundreds of health professionals add the CDE® credential after their name. We created this App because we believe in giving health care professionals practical tools for the CDE Exam plus access to critical resources that improve patient care.


Nothing in this website constitutes medical advice nor is it a substitute for medical advice.
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B J Venn 1 and J I much higher peak responses of glucose and insulin than meals consisting of whole grains of rice.
It does this by blocking the sodium-glucose co-transporter-2 (SGLT2) which is a protein in the kidney that is responsible for reabsorbing glucose back into the body. Both doses provided better reductions in HbA1C from baseline relative to placebo when used as a monotherapy and as an add-on therapy to metformin, sulfonylureas, metformin plus a sulfonylurea, metformin plus pioglitazone, and insulin.
The subjects received Invokana 300 mg or sitagliptin 100 mg in combination with metformin and sulfonylurea. Serious side effects of Invokana include kidney problems, hyperkalemia (high levels of potassium in blood), and hypotension (low blood pressure). The dose of Invokana may beed to be increased if combined with drugs that increase its removal from the body.
These opt-out decisions will leave millions uninsured who would have otherwise been covered by Medicaid, but the health and financial impacts have not been quantified.
Applying these figures to estimates of the effects of insurance expansion from prior studies, we calculate the likely health and financial impacts of states’ opt-out decisions. Based on recent data from the Oregon Health Insurance Experiment, we predict that many low-income women will forego recommended breast and cervical cancer screening; diabetics will forego medications, and all low-income adults will face a greater likelihood of depression, catastrophic medical expenses, and death.
The number of uninsured people in states opting in and opting out of Medicaid expansion is displayed in Exhibit 1.
We estimate the number of deaths attributable to the lack of Medicaid expansion in opt-out states at between 7,115 and 17,104.  Medicaid expansion in opt-out states would have resulted in 712,037 fewer persons screening positive for depression and 240,700 fewer individuals suffering catastrophic medical expenditures.
In Texas, the largest state opting out of Medicaid expansion, 2,013,025 people who would otherwise have been insured will remain uninsured due to the opt-out decision. We used the Census Bureau’s 2013 Current Population Survey, a nationally representative survey of the non-institutionalized US population, to determine the number of uninsured people in each state before implementation of the ACA. The OHIE is a randomized study that examined the effects of expanding public health insurance for low-income (less than 100 percent FPL) adults on health, financial strain, health care use, and self-reported well-being.  It found that after an average of 17 months of exposure to Medicaid coverage, improvements occurred in rates of depression (based on the eight-question version of the Patient Health Questionnaire (PHQ-8)), and catastrophic medical expenditures. For our high estimate, we used the recent study by Sommers and colleagues that compared trends in mortality rates in states with Medicaid expansions (New York, Maine, and Arizona) to trends in states without such expansions.
Our figures, which use the number of uninsured in 2012 as the baseline, differ slightly from Congressional Budget Office figures based on projections of the numbers who would have been uninsured in several future years had the ACA not been passed.
Similarly, we did not attempt adjustment for regional differences in depression prevalence, in the uninsured population, although such differences are probably small.
I live in Vermont and know that Vermont is an opted in state Please change your Map Graphic to reflect the TRUTH. But at an added cost north of $5,000 per person, Medicaid has to do more than merely reduce out-of-pocket spending to justify its costs.
The claim that it likely understates the potential mortality gains from Medicaid expansion lacks credibility, especially since that gain is based on a comparison of the uninsured with those on private insurance.
We did note that a broad Medicaid expansion may indeed strain the limited number of providers accepting Medicaid patients, a problem perpetuated by low reimbursement rates.
But he fails to note that the mortality increase in Maine was also non-significant, thus Conover’s comparison of Maine to New York (where Sommers found a significant mortality decrease) is a misapplication of a non-significant point estimate. In light of the mountain of evidence showing the private insurance is vastly superior to Medicaid when it comes to health outcomes, including mortality. It’s notable that on every metric of health risk (obesity, lack of exercise, smoking, drinking) the uninsured led riskier lives (Table 1). That the authors fail to even mention this study or explain their rationale for selecting the one whose results they prefer is equally inexcusable. Had a different, more appropriate comparison state been selected, the estimated beneficial effect of Medicaid expansion might well have disappeared entirely. When the ACA was passed, I was quite optimistic that the community efforts to care for the uninsured would be considerably enhanced by the new law. Type 2 diabetes is defined as a syndrome characterized by insulin deficiency, insulin resistance and increased hepatic glucose output. Metformin works by reducing hepatic glucose output and, to a lesser extent, enhancing insulin sensitivity in hepatic and peripheral tissues. Subsequently, in March 2000, the FDA asked the manufacturer (Parke-Davis, Warner-Lambert) of troglitazone, the first agent in this class to receive labeling approval, to remove the product from the market. Because they inhibit the breakdown and subsequent absorption of carbohydrates (dextrins, maltose, sucrose and starch; no effect on glucose) from the gut following meals, the largest impact of these drugs is on postprandial hyperglycemia. References in this website to any and all specific products, services or processes do not constitute or imply an endorsement or recommendation by Diabetes Educational Services. You should prevent spreading and the childhood weight problems; Late Onset Type 1 gestational pregnancy diabetes diet Diabetes Symptoms in case you have a good addict must find the eye.
Do not use these types of insulin if there are clumps in the liquid or if there (for example the thigh).
The most common symptoms of type 1 diabetes mellitus (DM) are polyuria polydipsia and polyphagia along with lassitude nause and Inquire as to whether the patient has a history of foot ulcers or amputations or whether any foot ulcers are present.
When a dog’s blood glucose is low he does not Avoiding Gestational Diabetes Second Pregnancy Flashing Eyes want to chase the ball or go for a walk. Women suffering from gestational diabetes also have the risk of developing type 2 diabetes and many other health issues in future. Lowering high blood glucose can help prevent nerve problems, blindness, and kidney damage in people with diabetes. Most recently, the Oregon Health Insurance Experiment (OHIE) found a striking increase in emergency department use as well as other outpatient care. Medicaid expansion in these states would have resulted in 422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64.
We estimate that Medicaid expansion in that state would have resulted in 184,192 fewer depression diagnoses, 62,610 fewer individuals suffering catastrophic medical expenditures, and between 1,840 and 3,035 fewer deaths.
We then projected the number of uninsured people in each state after implementation of the ACA depending on whether the state is opting in or opting out of Medicaid expansion. In addition, the OHIE found that acquisition of coverage led to increased utilization of most types of health care, including several types of care that has been linked to improved outcomes such as diabetics receiving medication to treat their diabetes and clinically indicated mammograms and cervical pap smears (in the past 12 months).
We could not take into account several factors that might influence the impact of Medicaid expansion.
If anything, the adjusted prevalence of major depression in Oregon appears slightly below the national average. It is listed as an opt-in state, but has a reduction in uninsured (18%) typical of opt-out states. The existing Medicaid program has been opened to single people and others not previously eligible.
Much of this evidence also is observational but the best studies, which take into account selection effects, show that private coverage is superior, e.g.
So it is not at all implausible to imagine they are more prone to dying in motor vehicle accidents due to lack of seatbelt use, speeding etc. This study is structured in the same fashion as the AJPH study but with very different results: Kronick found no statistically significant difference in mortality risk for those who were uninsured compared to those with employer-based coverage. Medications used to treat type 2 diabetes are designed to correct one or more of these metabolic abnormalities. It is of particular concern with agents that are metabolized to an active metabolite with significant renal excretion. What do you suggest for lab tests for diabetes patients weekly recipes women’s eakfast? By using a colour chart or a small glucose meter machine the blood level of glucose can be measured quickly.
Proper control of blood glucose can also decrease the risk of getting a heart attack or stroke.
Invokana 300 mg provided greater reduction from baseline in HbA1C compared to glimepiride, and the relative treatment difference was -0.12%.
Because the federal government will pay 100 percent of increased costs associated with Medicaid expansion for the first three years (and 90 percent thereafter), opt-out states are also turning down billions of dollars of potential revenue, which might strengthen their local economy. Expansion would have resulted in an additional 658,888 women in need of mammograms gaining insurance, as well as 3.1 million women who should receive regular pap smears.


Based on previously published estimates of take-up rates and estimates from the Congressional Budget Office, we assumed that in states opting out, 90 percent of currently uninsured people with incomes below 138 percent of FPL will remain uninsured, as will 75 percent of uninsured people with incomes above 138 percent FPL.
An estimate of the number needed to insure was calculated by dividing the number of newly insured persons by the number of outcomes achieved.
For instance, both the OHIE and Sommers estimates are based on Medicaid expansions that paid doctors pre-ACA reimbursement rates. An older sample population in the OHIE may have resulted in greater improvements in health and screening following Medicaid expansion, leading to a slight overestimate of effects in states with a younger uninsured population, whereas the female predominance in the OHIE may have resulted in a slight underestimate of effects in other states because males are more likely to have diabetes and other chronic conditions.
To make room for them, former recipients making over 100% of poverty were moved out and expected to buy insurance through the exchanges. A recent study by the Kaiser Family Foundation finds that overall state expenditures will be 2.9 percent greater between 2013 and 2022 compared to if all states opted out, whereas federal expenditures will be 26 percent greater. The AJPH study merely examines the uninsured and privately insured in year 1 and then measures what fraction have died 6-14 years later.
Woolhandler and Himmelstein would not prescribe to their patients a treatment demonstrated to have killed 1 out of every 2 who took it etc.
Currently, there are five distinct classes of hypoglycemic agents available, each class displaying unique pharmacologic properties. These agents include chlorpropamide (Diabinese) and glyburide, both of which should be avoided in the setting of impaired renal function and used with caution in elderly patients. Most of the related side effects (including metallic taste, gastrointestinal discomfort and nausea) are transient and commonly reported only during initiation of therapy. Demographic characteristics diagnosis of diabetes and Obesity and hyperlipidemia are risk factors for early diabetic neuropathy. With gestational diabetes in pregnancy forum symptoms does affect stress vildagliptin doses ranging from 25 mg Can Someone Please Tell Me Whats Going On? In states opting in, we assume that 40 percent of currently uninsured people with incomes below 138 percent FPL will remain uninsured, as will 60 percent of uninsured people with incomes above 138 percent FPL. For our low estimate, we used a study based on mortality follow-up of participants in the National Health and Nutrition Examination Study, which found a 40 percent increase in death rates among the uninsured, an effect size approximately 42 percent that found by Sommers. Since the ACA will provide a two-year increase in Medicaid rates for primary care services, it is possible that access to care will improve more than was observed in those studies if more providers start accepting Medicaid. Table 2 in Sommers shows that the mortality change observed in Maine was statistically signficant from New York’s, but that does not entirely rule out the possibility of a net mortality gain in Maine. It does not examine the causes of deaths, including many that would have nothing to do with health insurance.
It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.” Since the AJPH study merely updates the IOM estimate using a different dataset, Kronick’s observation applies to it with equal force.
These classes are the sulfonylureas, meglitinides, biguanides, thiazolidinediones and alpha-glucosidase inhibitors.
Unlike the commonly used sulfonylureas, the meglitinides have a very short onset of action and a short half-life. Therapy with acarbose has been linked to elevations in serum transaminase levels and the use of this agent is contraindicated in patients with liver cirrhosis.
A test measuring the fasting blood sugar level after an overnight fast with periodic testing for the next several hours after drinking a sugary liquid.
These estimates incorporate the assumption that enrollment of people with incomes above 138 percent FPL through the exchanges will be higher in states that opt to expand Medicaid.
In addition, Oregon’s health costs (and presumably its rates of catastrophic medical expenditures) are slightly lower than national average. The broader expansion under the ACA may put greater strain on the limited capacity of providers who accept Medicaid patients, curtailing utilization. In patients for whom diet and exercise do not provide adequate glucose control, therapy with a single oral agent can be tried. All sulfonylureas have been associated with weight gain and thus, may not be the optimal first choice for obese patients.Unfortunately, not all patients treated with a sulfonylurea will have an adequate response.
Taking the drug with meals may also lessen the severity of the gastrointestinal side effects.
Patients treated with pioglitazone have displayed mean decreases in triglyceride levels, mean increases in HDL cholesterol levels, and no consistent mean changes in LDL and total cholesterol levels.20,21Because these agents do not increase insulin secretion, hypoglycemia does not pose a risk when thiazolidinediones are taken as monotherapy.
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Finally, participants in the OHIE had been uninsured for at least six months, and were concentrated in the Portland area.
The Sommers study examined 3 states and Medicaid was found to have a statistically significant effect in only one. When choosing an agent, it is prudent to consider both patient- and drug-specific characteristics. Treatment failure with sulfonylurea therapy can be divided into two categories: primary and secondary. If a meal is omitted throughout the day, patients should be instructed to skip the corresponding dose to prevent hypoglycemia.
Because metformin does not affect insulin secretion, it is not associated with hypoglycemia when used as monotherapy, but can potentiate hypoglycemia when used in combination with a sulfonylurea or insulin.
Other contraindications include patients with inflammatory bowel disease or a history of bowel obstruction.32Therapy should be initiated with the lowest effective dose and titrated slowly over intervals of two to four weeks.
Yet the Dickman team essentially extrapolated that mortality benefit to EVERY state even though we have no reason to believe that most states would be similar to NY than to ME or AZ. If adequate blood glucose control is not attained using a single oral agent, a combination of agents with different mechanisms of action may have additive therapeutic effects and result in better glycemic control.
Primary failure results when a patient exhibits an initial poor response to sulfonylurea therapy (a decrease in FPG levels of less than 20 mg per dL [1.1 mmol per L]).
Likewise, if an extra meal is added throughout the day, the patient should add a dose to cover that meal. Repaglinide can be titrated to a dosage of 4 mg before each meal (maximum dosage of 16 mg per day). The Dickman methodology concludes that 31 lives would be saved in Maine from Medicaid expansion even though the very study they use to make that extrapolation specifically found that Maine’s Medicaid program had no statistically significant effect on mortality.
The use of thiazolidinediones should be avoided in these patients.As referred to earlier, of greatest concern are the reports of an idiosyncratic drug reaction with troglitazone. Although hypoglycemia is not typically associated with monotherapy with the alpha-glucosidase inhibitors, it can occur in combination with other drugs. Given that the Sommers team cautioned specifically against precisely this sort of extrapolation, it’s pretty inappropriate to quote their conclusion without alerting readers to this caveat. Most of the hypoglycemic effects of the sulfonylureas will be observed at one half of the maximum dose recommended for a specific agent. At least one week should be allowed between dosage adjustments to adequately assess blood glucose response. This reaction is initially characterized by increased serum transaminase levels, which in some cases progressed to hepatitis, hepatic failure and death. In patients undergoing contrast studies, metformin therapy should be withheld for approximately 48 hours following the procedure or until it has been determined that renal function has returned to baseline. Preliminary attempts (before troglitazone was withdrawn from the market in March 2000) to prevent such incidents included a request by the FDA that Parke-Davis strengthen the drug's labeling and require stringent monitoring of transaminase levels in patients taking this agent.
In March 1999, the FDA's Endocrine and Metabolic Drugs Advisory Committee reviewed the status of troglitazone and the potential toxicities and recommended continued availability in a select group of patients: those who are not well controlled with other antidiabetic agents.
Since then, it has been determined that patients requiring the use of an insulin sensitizer should be treated with one of the alternative agents.
Although results from pre-marketing trials revealed no evidence of hepatotoxicity with the newer agents (rosiglitazone and pioglitazone), two recent case reports demonstrated that rosiglitazone may be associated with hepatic failure following just 14 days of therapy, although a true cause-and-effect relationship has not been established.26,27The FDA recommends that serum transaminase levels be monitored every other month for the first year in all patients receiving a thiazolidinedione.
Following one year of therapy with the newer agents, the incidence of serum transaminase elevations has been reported to be similar to placebo.The time to achieve a desired effect with the thiazolidinediones is somewhat longer than the other classes of hypoglycemic agents discussed thus far.
Intervals of at least three to four weeks should be allowed before increasing the dosage of these agents.
Smaller dosages can be initiated if used as part of a combination regimen with a sulfonylurea or a sulfonylurea plus metformin.



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