Category Archives: Diabetes

Price Check! Are analogue insulins worth their hefty price?

The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir).

Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them.

But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen) Continue reading

Grody Feet and Heel Cracks

Back when I worked in the ER, we often would have patients come to the ER who were homeless or otherwise had not been taking care of themselves. Of particular concern was their feet—many had not removed their shoes for days or even weeks. When these shoes were removed, we often were confronted by a dreaded medical malady: Toxic Sock Syndrome.  These feet could be unbelievably odiferous—I have seen hardened paramedics retch.

So we had to be careful. If a patient was suspected of having Toxic Shock Syndrome, shoes and socks would be quickly removed into a plastic bag and the feet immediately washed and covered with clean slippers.

That was about the end of ER involvement with poorly-cared-for feet. As an ER Doc, I never had to do much with the underlying foot disease.

The situation has been reversed now that I work in jails and prisons. I don’t have to deal with Toxic Sock Syndrome anymore. (I’m sure the booking deputies do, though. Bless them). Instead, a day or two later I typically am confronted in the jail medical clinic with the grody feet themselves. Here is a typical example:Foot

The medical term for such feet is PalmoPlantar Keratoderma or PPK. Continue reading

Changes in Hypertension Treatment? Why Yes! The Recommendations of JNC 8

As we all know from long experience, hypertension is the single most commonly seen and treated condition in primary care medicine. It is an important risk factor for strokes, heart attacks, kidney failure and overall death. It has been exhaustively studied. And yet there is still significant controversy over hypertension, including how to define it and what the best agents for treatment are.
Against this background, The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults was released last December in JAMA. It was written by the 8th Joint National Committee, and so, of course, is referred to as JNC 8.

JNC 8 has a couple of important and surprising changes from JNC 7. One of these, at least, is controversial enough that some members of the committee rebelled and released a dissenting “Minority Report” (apologies to Tom Cruise). Today’s JailMedicine post is a summary of JNC 8 recommendations and changes to JNC 7.20140430 Continue reading

The Bright Side of Metabolic Syndrome!

I have been doing yearly wellness exams for the local fire fighters for many years now.  I quite enjoy it.  Many of them are in such good physical shape that I pronounce them to be “Mary Poppins” fire fighters, meaning  “Practically Perfect in Every Way!”  Many, however, succumb as they get older to the “weight creep” that is common in the US today.  I saw one such firefighter this very week who had gained 8 pounds since I saw him last year.  In such cases, I have to educate the patient about the Medical Consequences of Excess Weight.  There is even a medical term for this phenomenon:  “Metabolic Syndrome.”  I think that just about everyone, whether a firefighter, an inmate in a prison or jail, or the medical staff that takes care of them, should understand Metabolic Syndrome.20070613 Continue reading

Reader Question: How Do You Handle Ramadan At Your Facility?

Dr. Keller,
I am curious to see how other jails/prison handle fasting during Ramadan. We only KOP inhalers and creams at my facility and have no medical commissary. We do a very early medication pass for those who are fasting, but it does cause occasional problems with the management of diabetics and some other chronically ill patients. How do other facilities handle this?
Thanks,
 Jill McNamaraimages-2 Continue reading

Reader Question: Diabetic Malingering Part 3

Janet, great correctional nurse, Ada county Jail, Boise

Dr. Kay Haw submitted the following question:

“I would like to know your thoughts on the ability to forcibly provide insulin coverage on a diabetic inmate whose sugars are out of control and is refusing blood sugar checks and insulin administration.”

This is a great question that I should have answered as part of the Diabetic Malingering series found here and here.  The question here is whether an inmate has a right to refuse medical care, even if doing so could result in harm.  In general, inmates retain the right to refuse medical care, as long as they are competent to do so and as long as the refusal is informed (more on that later). However, this right of refusal is not inalienable and  depends on clinical circumstances, such as how much harm the patient faces by the refusal, the reason the patient has for refusing and the patient’s competence.

In the case of refusing insulin, the risk the patient faces depends on whether the patient is a Type 1 diabetic or a type 2 diabetic. A Type 1 diabetic will eventually die without insulin and may lapse into a diabetic keto-acidosis coma in as soon as 3-4 days.  Type 2 diabetics, on the other hand, will not die without insulin.  They still make their own insulin.  They are insulin resistant but not insulin dependent.  Some are prescribed insulin to keep their blood sugars down, but they do not need insulin to survive.

Refusal of Insulin by a Type 2 Diabetic

So let’s first take the simpler case of a Type 2 diabetic who refuses to take insulin.  Since he does not need insulin to survive, and since insulin is not the only treatment option available, the refusal of insulin is analogous to the same patient refusing a diabetic diet.  It may not be in his best interest to refuse insulin (or a diabetic diet) but the patient has the right to refuse these treatments as long as the refusal is an informed refusal.  An informed refusal entails that someone, usually the jail practitioner, informs this patient of the potential harm that might ensue as a result of refusing medical care.  I would talk about the risk of heart attacks, strokes, kidney failure, blindness, foot amputations and every other complication of diabetes I can think of.  Besides warning him of the possible consequences of his refusal, I might just scare him enough to reconsider.  The threat of impotence seems to work particularly well in the scaring department!

After this, assuming that the patient continues to refuse care, I inform him that he can change his mind at any time and document the conversation thoroughly in the medical record.  There are times when you can be brief in your medical documentation but this is not one of them.  You need to document the risks you discussed with the patient, the fact that he refused and that you told him he could change his mind.  That’s the easy case.

Refusal of Insulin by a Type 1 Diabetic

The refusal of insulin by a Type 1 diabetic is a totally different case since type 1 diabetics are dependent on insulin to survive.  Without insulin, they can lapse into a diabetic coma in as little as 3-4 days.  The threat is real and immediate. The first question to ask a Type 1 diabetic who is refusing insulin is whether he understands this and whether he is intending to commit suicide.  In fact, for Type 1 diabetics, the conversation on adverse consequences can be much shorter than for Type 2 diabetics.  All you really have to say is “Without insulin, you will die.  Maybe within days.  Do you understand this?”

If the patient continues to refuse insulin despite this warning, my personal opinion is that, in most cases, this jail inmate should be forcibly restrained and given insulin despite his refusal.

“Wait!” you might be saying.”What about the inmate’s right to an informed refusal of medical care?” Well, there are several  issues here that bear on my decision to override this particular inmate’s right to refuse care.

1. What is the inmate’s motivation for refusing this life-saving medical intervention? There is a difference between a patient who is refusing life-or-death medical care for religious reasons (Like Jehovah’s Witness refusing blood products) versus refusing due to a trivial protest of jail policies or wanting to commit suicide.   I do have not have much respect for a patient who is refusing insulin as a method of manipulation.  And inmates do not have an innate right to manipulate.

2.  Inmates do not have a right to commit suicide.  Just as an inmate does not have the right to kill themselves by refusing oxygen (by wrapping a sheet around their neck), they also don’t have the right to kill themselves by refusing insulin.

3.  The threat to a Type 1 diabetic’s health of refusing insulin is immediate.  Without insulin, they may lapse into a coma within days.  There often is not enough time to adjudicate the question in court.  If, instead of wanting to commit suicide by refusing insulin, an inmate wanted to commit suicide by refusing food and starving to death, there would be plenty of time to get a judges opinion.  Death by starvation takes weeks.  Death by diabetic coma takes days.  I need to act now.

4. The solution to this dilemma is relatively quick and easy.  In order to keep a Type 1 diabetic alive, all we really need to give them is long acting basal insulin, either Levemir or Lantus, once a day.  And patients need only be restrained for literally seconds, just long enough to get a blood sugar and give insulin.  Patients won’t be well controlled with just Lantus, but it will keep them alive long enough to go to court, if necessary. More typically in my experience, after the first forced shot, patients usually change their mind and again accept diabetic care.

5. Finally, incarcerated inmates, to some degree, have lost absolute autonomy to make their own decisions.  Just like an inmate cannot choose what to eat or to wear, they do not have an inalienable right to refuse medical care when in jail.  Jails, prisons and juvenile facilities have some degree of guardianship over incarcerated inmates and also have not only the right, but the responsibility to protect the well being of the inmate as well as the safety and security of the institution.

“I’ll take insulin, but I refuse to allow you to take blood sugars.”

What about the patient who accepts insulin, but refuses to allow blood sugar checks?  Again, in my mind, this boils down to the risk the patient faces by this refusal.  Since a shot of insulin can potentially kill a person whose blood sugar is low, knowledge of the blood sugar is mandatory to be able to give insulin safely.  I would not allow a patient to accept insulin but refuse blood sugar checks.  They must go together.

What I have written here is my own opinion.  I freely admit that smart people might just disagree with me!  In fact, I might be wrong!  You should discuss this potential situation with your facitily’s legal counsel and administration so you know in advance what you are going to do when the time comes.  And it will happen!  This is not that uncommon of a situation.

What would you do in the case of a Type 1 diabetic who is refusing insulin?  Please comment!

Special Thanks to David Tatarsky, General Counsel to the South Carolina Department of Corrections, for teaching me how to look at this case from a legal perspective.  Of course, if I have made a mistake, it is my mistake, not his!

 

Essential Pearls from Essentials

Essentials of Correctional Medicine was held last week in Salt Lake City, Utah and included some great talks.  Today’s post is a list of Pearls I gleaned from the conference speakers.

The definition of a “Pearl” is a bit of pithy and insightful information that can be communicated in one or two sentences. Hopefully, it is also something that you have not thought of yet and will change your practice for the better.

I ran into several Pearls at the Essentials conference. Here is a sampling (in no particular order): Continue reading

Diabetic Malingering, Part Two. Scams and Solutions!

My last post introduced the subject of diabetic malingering.  In this post, I present several patients I have encountered in my correctional medicine career and the various scams they have used to manipulate their blood sugars. Continue reading

Diabetic Malingering: Part One

Happy Halloween!

In corrections, we see an awful lot of malingering, symptom magnification, and outright medical deception.  This comes in many forms, from alleging vomiting when none has occurred, to falsely claiming to be hearing “voices,” to deliberately abrading the skin and then complaining that medical can’t get rid of “my rash.”  From never-ending back pain with vague leg numbness to pseudo-seizures.  But of all of the many kinds of behaviors of this sort, the one that is perhaps the hardest of all to deal with and carries the greatest risk of adverse outcomes is diabetic malingering. Continue reading

Six Months Later–Top Posts

Well, JailMedicine is now over six months old and has been more fun to write and much better received than I had imagined it would be.  JailMedicine has had over 30,000 hits!  Thank you especially to those of you who have written comments.  I have my opinions on certain topics (as you have read) but I realize that smart and accomplished people sometimes disagree with me–and sometimes they are right and I am wrong!  We all learn and become more effective clinicians when alternative views are expressed and debated–so please comment!

What can I do to make JailMedicine better? Continue reading