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Post by silentbob on Mar 20, 2015 8:52:59 GMT -5
Congrats on your progress Spiro!
You would think that such an effective medicine would catch on faster...
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Post by babaoriley on Mar 20, 2015 10:21:04 GMT -5
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Post by dreamboatcruise on Mar 20, 2015 10:24:16 GMT -5
Hey Spiro my wife the doc says after latest medical conf. That diabetes should be diagnosed on fasting glucose and two hour post prandial not a1c. What say to dat mumbo jumbo? While Al has long said that A1C isn't a good metric for measuring control of diabetes once someone is on insulin, since it averages treatment induced hypos against diabetes induced hypers rather than giving a good indication of amount of time within the healthy range... I'm curious about this assertion regarding a better way of diagnosing. Obviously there are some logistical issues since one visit to the docs office/lab can't both test for fasting and 2 hr post prandial. Perhaps you could ask why that is the case for diagnosing... and was the info from informal discussions or a presentation by someone... who? |
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Post by brentie on Mar 20, 2015 10:34:58 GMT -5
Sounds like a nice place, Spiro. Not much different than Florida.  |
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Post by dreamboatcruise on Mar 20, 2015 10:40:48 GMT -5
It's like a white sandy beach that stretches on forever. Making daiquiris there would be easy.
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Post by tripoley on Mar 20, 2015 10:59:54 GMT -5
Hey Spiro my wife the doc says after latest medical conf. That diabetes should be diagnosed on fasting glucose and two hour post prandial not a1c. What say to dat mumbo jumbo? While Al has long said that A1C isn't a good metric for measuring control of diabetes once someone is on insulin, since it averages treatment induced hypos against diabetes induced hypers rather than giving a good indication of amount of time within the healthy range... I'm curious about this assertion regarding a better way of diagnosing. Obviously there are some logistical issues since one visit to the docs office/lab can't both test for fasting and 2 hr post prandial. Perhaps you could ask why that is the case for diagnosing... and was the info from informal discussions or a presentation by someone... who? It's called a glucose tolerance test. They check your blood glucose fasting, have you drink some glucose and check your BS afterwards, often at 30 minutes, one, two and three hours. |
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Post by dreamboatcruise on Mar 20, 2015 11:06:11 GMT -5
What is the benefit of that vs A1C for initial diagnoses? Are there some circumstances where an A1C that would be considered only prediabetic or even normal might have a worse underlying condition revealed by that glucose challenge? My knowledge on that is pretty limited.
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Post by spiro on Mar 20, 2015 11:58:48 GMT -5
Spiro saw his A1c over 6 on his last 18 or so blood workups. It took over 6 years to hit 7.1. I guess Spiro's doctor was pretty confident about him being a Diabetiic, because much to Spiro's displeasure, the doctor had been calling Spiro a diabetic since 6.0 The biggest factor that fostered Spiro's denial was the BG monitor that kept reading near 100 every time he checked it in the morning. Until Afrezza gets approved in Siberia, that may not be an option. Maybe Mrs. Spiro will send him to the northern fringes of Alaska.
Spiro here
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Post by jpg on Mar 20, 2015 13:57:32 GMT -5
What is the benefit of that vs A1C for initial diagnoses? Are there some circumstances where an A1C that would be considered only prediabetic or even normal might have a worse underlying condition revealed by that glucose challenge? My knowledge on that is pretty limited. Since the first thing lost in type 2 is the prandial spike in insulin relying on a rising A1C is of limited diagnostic value if the aim is to 'catch' diabetes early. Doing a fasting and glucose challenge (although in itself far from physiological) is a more sensitive and earlier marker of pre diabetes or early diabetes. Once your HbA1C starts to rise you are no longer an early diabetic and certainly not a pre diabetic (as surprisingly many seem to think). The down sides of doing provocation test are the usual time and $. Post glucose challenge test are used relatively frequently in pregnancy but not routinely in the general population. |
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Post by dreamboatcruise on Mar 20, 2015 14:11:48 GMT -5
What is the benefit of that vs A1C for initial diagnoses? Are there some circumstances where an A1C that would be considered only prediabetic or even normal might have a worse underlying condition revealed by that glucose challenge? My knowledge on that is pretty limited. Since the first thing lost in type 2 is the prandial spike in insulin relying on a rising A1C is of limited diagnostic value if the aim is to 'catch' diabetes early. Doing a fasting and glucose challenge (although in itself far from physiological) is a more sensitive and earlier marker of pre diabetes or early diabetes. Once your HbA1C starts to rise you are no longer an early diabetic and certainly not a pre diabetic (as surprisingly many seem to think). The down sides of doing provocation test are the usual time and $. Post glucose challenge test are used relatively frequently in pregnancy but not routinely in the general population. So the prandial insulin spike is lost before A1C starts to rise? or does A1C rise some, but staying below where most doctors initiate treatment, and then after some time in the "prediabetic" 6 to 7 A1C range, the insulin spike fails? My limited understanding of things, I would expect that A1C levels would rise once prandial insulin spike diminishes as the liver wouldn't receive the signal to stop releasing glucose. |
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Post by jpg on Mar 20, 2015 14:33:17 GMT -5
Since the first thing lost in type 2 is the prandial spike in insulin relying on a rising A1C is of limited diagnostic value if the aim is to 'catch' diabetes early. Doing a fasting and glucose challenge (although in itself far from physiological) is a more sensitive and earlier marker of pre diabetes or early diabetes. Once your HbA1C starts to rise you are no longer an early diabetic and certainly not a pre diabetic (as surprisingly many seem to think). The down sides of doing provocation test are the usual time and $. Post glucose challenge test are used relatively frequently in pregnancy but not routinely in the general population. So the prandial insulin spike is lost before A1C starts to rise? or does A1C rise some, but staying below where most doctors initiate treatment, and then after some time in the "prediabetic" 6 to 7 A1C range, the insulin spike fails? My limited understanding of things, I would expect that A1C levels would rise once prandial insulin spike diminishes as the liver wouldn't receive the signal to stop releasing glucose. The first thing that goes is the prandial control of glucose. This minimally affects HbA1C because it doesn't affect area under the curve or mean glucose concentration that much. It does raise A1C a little bit though but not enough to make A1C a sensitive or specific test to reliably pick up pre or very early diabetics. A1C also tends to increase 'gently' with age for various reasons that can be interpreted many ways depending on your point of view of many other things... I'm not trying to be cryptic here but it's complicated and part of this has to do with public health policies. Does picking up pre or very early type 2 diabetics make a meaningful difference to public health? I would say yes if we could institute disease modifying correctives (lifestyle as in the usual 'weight loss, changing diet and exercise' that everyone knows about but seems to be such a real world challenge and/or Rx) but that is also another topic and there is no drug that fills that description yet. A weight loss pill (I am not saying I think this is a good idea and have no stake in any weight loss company), metformin or Afrezza could be potentially in this category. All 3 drugs mentioned would work by slightly different mechanisms and could even be potentially synergistic. |
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Post by dreamboatcruise on Mar 20, 2015 16:21:22 GMT -5
jpg... thanks. I think I understand. Based on the tendency for A1C to rise with age, for someone in their mid 70's, at what level of A1C would you say it would become important to do the glucose test to evaluate prandial response? My mother has high A1C but I think has been relatively stable for years now or with only slight increase.
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Post by jpg on Mar 20, 2015 17:07:45 GMT -5
jpg... thanks. I think I understand. Based on the tendency for A1C to rise with age, for someone in their mid 70's, at what level of A1C would you say it would become important to do the glucose test to evaluate prandial response? My mother has high A1C but I think has been relatively stable for years now or with only slight increase. As I am becoming aware that our board is no longer read only by a small group of 'Manniacs' investors (as our dear friendly shorts call us) and maybe by the occasional patient and MD interested in these topics I will have to be careful as to what I state (it's not as if I have the most secret user name...): T your question I would conclusively say: it depends... Scenario 1: metastatic cancer with a life expectancy of 1 year. Obviously diabetes is not a big concern... Scenario 2: heathy, fit, no smoker, married, college educated, 100000$ annual family income, BMI of 25 white American women with a life expectancy of about on average 93 years (so another 20 years to live on average). Big difference obviously. gosset.wharton.upenn.edu/~foster/mortality/perl/CalcForm.htmlDoctors don't use this type of life expectancy tool for patient (maybe we should?) but you get my point. At the same time BP, cholesterol diet etc. all come into play. I don't do primary care but hospital based stuff and this 'fine tuning' is not my area of expertise and the data is so confusing because we don't have good answers. Answers are much simpler to give when the data makes sense. Do I treat the average mid 70 yr patient with an above 6.5 A1C? Yes at the very least I get the ball rolling for nutritional/ lifestyle advice and a follow up. Will some disagree? Probably. Is there a paucity of good outcome data on who and how to treat these patients? Absolutely. I personally think one of the big flaws starts with the measure we use to make decisions with: A1C. It's useful to make decisions in the extremes but is maybe sub optimal when 'not so high' and for fine tuning. The problem might be 1. A1C is what we have been using as a roadmap to treatment and 2. the drugs we use to treat are not all equally beneficial. We constantly hear people saying A1C is not good and it's not really precise (and giving all these explanations why theirs is artificially high or low) but then we all turn around and want to treat the A1C. Even the most 'anti A1C' on the diabetic boards get into arguments about how to treat something they themselves don't really fundamentally believe in. Again it is complicated but there is a catch 22 error in our thinking about diabetes and A1C is central to our error in logic. Without better data I think many of these decisions will be as much art and guess work as science. Now that I have said all this I will refer you to the CGM tread I posted on recently... I again think this is how we will get many of the answers we need to get to be able to make better well informed decisions that have huge public health importance for our aging diabetic population and yes I firmly believe Afrezza will (eventually) play a central role in at least a significant part of all this. JPG PS: If any MDs or patients read this please feel free to join in but do keep in mind I am speaking primarily to other investors and not giving any medical advice. |
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Post by tripoley on Mar 20, 2015 17:23:33 GMT -5
Spiro saw his A1c over 6 on his last 18 or so blood workups. It took over 6 years to hit 7.1. I guess Spiro's doctor was pretty confident about him being a Diabetiic, because much to Spiro's displeasure, the doctor had been calling Spiro a diabetic since 6.0 The biggest factor that fostered Spiro's denial was the BG monitor that kept reading near 100 every time he checked it in the morning. Until Afrezza gets approved in Siberia, that may not be an option. Maybe Mrs. Spiro will send him to the northern fringes of Alaska. Spiro here This is why a HgbA1c <6.0, FBS <109 and 2 hour PP <154 matters:  Diabetic retinopathy goes from <5% to ~15% in 40 to 74 year olds above those levels. |
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Post by dreamboatcruise on Mar 20, 2015 19:45:05 GMT -5
Spiro saw his A1c over 6 on his last 18 or so blood workups. It took over 6 years to hit 7.1. I guess Spiro's doctor was pretty confident about him being a Diabetiic, because much to Spiro's displeasure, the doctor had been calling Spiro a diabetic since 6.0 The biggest factor that fostered Spiro's denial was the BG monitor that kept reading near 100 every time he checked it in the morning. Until Afrezza gets approved in Siberia, that may not be an option. Maybe Mrs. Spiro will send him to the northern fringes of Alaska. Spiro here This is why a HgbA1c <6.0, FBS <109 and 2 hour PP <154 matters: Diabetic retinopathy goes from <5% to ~15% in 40 to 74 year olds above those levels. Does that chart continue to shoot up for A1C over 6.2? That might be a useful tool for me to try to motivate someone to take action. |
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