The Last Straw or Grasping at Straws?

Straws. They hold useful place in our language. “The last straw” (that breaks the camel’s back). “The short straw” (usually a sign someone’s about to die in the movies). “Grasping at straws” (desperate attempt to salvage a situation).

Of late, however, straws have become quite the bête noire – at least the plastic ones. One jurisdiction in California passed a law calling for significant financial penalties and potential jail time for restaurant workers handing out straws. For a time, you couldn’t click on a news site without seeing a story about the horrors of plastic straws.

Where on Earth did this come from? Well, mainly from an oft-repeated “statistic” that Americans used some 500 million (that’s MILLION) straws every day. Then a magnificent leap was made to a further “statistic” about plastic pollution in the Earth’s oceans. Throw in a couple photos of sea otters or some other critters with straws up their nose, and it’s clear that the plastic straw is the greatest evil ever created.

First off, although a number of well-respected entities use the “500 millions straws a day” statistic, in reality it stems from a not-so-scientific science report written by an 8-year-old. Can we just back up a bit and wonder why anyone came to believe that number in the first place? The population of the United States – men, women and children – is approximately 330 million, so according to this statistic, every American uses 10 straws every week. Every American, every week – without fail. I don’t use straws of any sort, so somewhere out there someone is using 20 straws a week. I’m guessing infants don’t use them either, so there’s another 15 million Americans using 20 straws a week. Sorry, but “500 million straws a day” is an idiotic “statistic.”

Then we leap to plastic pollution in the waterways of the world. Well, yes, there is a lot of plastic pollution. But not from the U.S. Less than 1% of water-borne plastic pollution comes from the U.S. (and you can imagine that straws represent a miniscule portion of that). Virtually all of it comes from Asia and Africa. So some poor restaurant worker is exposed to criminal liability because Asian and African countries pollute their waterways? C’mon. Where’s the common sense?

For my part, I’ve been pretty “meh” on straws since about third grade, when straw manufacturers seemed to conspire to make it impossible to blow the straw sleeves across the cafeteria. If you think it’s better to have paper straws than plastic, that’s fine. But can’t we have these discussions without getting hysterical about it?

More on the CGM Trail

A while ago I wrote about using Abbott’s FreeStyle Libre continuous glucose monitor (CGM) which I had received complimentary from Abbott to sample.  Experience hasn’t dimmed my enthusiasm for the device, but I’ve also found that what’s great about this system doesn’t end with the device itself.

As anyone who has diabetes, or has to deal with someone with diabetes, learns over time is the dogged always-there nature of the condition.  Even if you are diligent about seeing your endocrinologist or GP every three months or so, that’s a lot of time contending with all the variables of diabetes on your own.

The advances in blood glucose meters – yes, the dread “finger stick,” but they’ve gotten better and better – was a great step forward for patients being able to adjust their daily behavior based on real information (rather than trying to interpret weird twinges and feelings in your body).  With many of those BG monitors, you could download the data onto your computer and try to spot trends.

Enter the CGM, which accurately shows recent trends right on the screen because it’s capturing your glucose levels every couple of minutes.  And,  you can go still further by downloading the CGM data into your computer and see longer-term trends.

Everyone talks about “patient empowerment ” – to the point of over-use, in my mind – but this is a case where it’s true, and the FreeStyle Libre interface is the best I’ve seen to really give you some power over this accursed disease.  From pattern graphs (daily, mealtime, etc.) to weekly and monthly summaries, plus a useful report called “Glucose Pattern Insights” you can get a very clear picture of what’s been going on with your blood glucose.  Equally cool, for whatever time period you choose, it gives you an estimate of your HbA1c.  It doesn’t replace your quarterly A1c blood test, but it certainly is a nice change from waiting to find out where that number is.

This functionality is all completely aside from the excellent patient support that Abbott provides.  I’ve used probably five different brands of blood glucose monitors, and two CGMs (and the DDaughter has been on a pump since she was 14), so I’m fairly well-versed in patient support.  Some are great (Abbott and MedTronic are tops in my view), some are working hard at getting great, and some just don’t seem to understand why patient support for diabetics is important.

My understanding is that the uptake on the FreeStyle Libre has been very strong, and I’m sure Abbott’s offer of a free device and a sensor for Dexcom users will stoke that furnace a bit more.

Coming up soon:  Getting off the purely-diabetes topics, an eye-opening primer on “sugar alcohols” – dieter’s delight, or demise?

I have seen the future, and it is now (CGM version)

Bear with me, non-diabetics.  This is about gob-smacking advances in medical technology, and it’s worth a read if for only to the marvels that we can still experience.

A while ago, I wrote about the FDA approval of Abbott’s FreeStyle Libre, a new continuous glucose monitor (CGM).  CGMs include a transmitter which reads your blood glucose level continuously, and displays the information on a pager-sized receiver in the form of a graph showing how your BG is trending.  For a T1D, the CGM seems like a luxury in theory, but in practice become indispensable in your diabetes management.

Several weeks ago, the good folks at Abbott gave me a complimentary FreeStyle Libre  for sampling purposes (@FreeStyleDiabet).

Several years ago, my endocrinologist introduced me to  the world of CGMs (with a DexCom G4), and I immediately understood the usefulness not only seeing my current blood glucose level, but where it had been over the past couple hours and whether it was rising, falling or staying steady.  Compared to the normal BG checking method – pricking your finger, putting a drop of blood on a strip, and getting a reading of the BG at that moment – the CGM was like suddenly being able to see in three dimensions.

Despite the general dependability of the DexCom G4, I stopped using their CGM about a year ago.  I can get into the reasons later; mostly it was a matter of convenience and customer service.  The device itself worked well.

The FreeStyle Libre shows what happens when technology advances, and the developer is listening the ultimate user.  Let’s start with the crown jewel of features:  once you put on the transmitter (which lasts 10 days), you don’t need to prick your finger.  AT ALL.  That’s right, no calibration with a BG meter.

For the non-T1Ds reading this, imagine that every day – every single day, with no abeyance for weekends, holidays or I-don’t-feel-like-it days – you had to prick your finger and draw blood.  Four, five or six times a day.  Then suddenly, you get a device that gives tons more information than the BG meter, with vampire-like fascination for blood dripping from your finger.

For the T1Ds reading this; you read the last paragraph correctly.  I’ve been on the FreeStyle Libre for three weeks and have pricked my finger  a total of six times (all during the admittedly-long 12 hours the CGM has to be inserted before you get readings).

The FreeStyle Libre transmitter is the size of two quarters stacked atop one another, and is inserted on the back of your arm (reverse side from the bicep).  It’s unobtrusive, and you just wave the receiver over it to get an instant reading. (Sorry Dexcom, but the ideal placement of your device was on my stomach, and looked like a tumor under my tee-shirt.  I dislodged more than a couple just hitching my belt up.)

My endocrinologist would yell at me if I didn’t also say that it’s important to use the CGM’s features to input how much insulin you take, food you eat and exercise you do (which helps the docs get a good picture of how and why your insulin is reacting to your activities).  Fortunately, on the FreeStyle Libre, the receiver (again, smaller than a pager and quietly sits in my pants pocket) has easy touch-screen inputting of insulin doses and carb consumption.

So, Abbott . . . yay!  You made a device that works great, and has features oriented toward making a diabetics’ life easier.  This is what innovation is supposed to look like.

In a later post I’ll talk about the computer interface (preview:  EXCELLENT).

Exceptions to the Over-used Word “Innovation”

If one can be considered a “fortunate” T1 diabetic (a dubious concept), I’ll call myself one.

When I was diagnosed, insulin was derived from pig and cow pancreases, came in a few varieties, and had wide +/- ranges on “time to peak action.”  If you wanted to “check your blood,” you slashed your fingertip, dropped huge globule of blood onto a reagent strip and after a minute, compared it to a color chart for your blood glucose measure.

We T1s benefit from real innovation.  Today, a host of reliable recombinant human DNA insulin (fast-acting and long-duration varieties), more (better, accurate) blood glucose meters than you can shake a stick at, and a few other very cool medical devices (the CD-Daughter, is a 12-year insulin pump veteran) make life vastly different for the T1 diabetic than when I was first diagnosed.

So, yeah, I count myself as fortunate.  And I’m a fan of the companies – really, the people who work for the companies – who developed these drugs and devices.

Then again, it’s not like we see these developments frequently – particularly for T1s.  There are a lot more T2s in the world, so they get the lion’s share of goodies intended for diabetics.

The other day, T1s got a pleasant surprise with FDA’s approval of Abbott’s Freestyle Libre continuous glucose monitor.  Full disclosure:  I loved my Freestyle blood monitor (until my insurance told me they didn’t cover it anymore).  And I liked my Dexcom G4 CGM (though I had a five month nightmare with the G5).  Yes, I’m predisposed to the CGM concept, and yes, I’m predisposed to Abbott.

The difference between checking your blood with normal “finger sticks” on the BG monitor and keeping track of it with a CGM is like the difference between knowing what temperature it is right now and having a five day weather report.  The CGM tells you the trends – when you’re sailing up, when you’re crashing down.  I can’t tell you the number of 260s and 60s I’ve avoided because the CGM showed me where I was headed.

But how cool is this?  The Freestyle Libre “patch” (it’s the size of two quarters stacked and adhere’s to your upper arm) is good for 10 days.  And you don’t have to calibrate it with finger sticks.  (The Dexcom is good for a week, and you have to calibrate twice a day with a BG machine.)

I believe more and better CGMs will be a very important step forward for T1s in keeping track of their blood glucose.  No dings on Dexcom; they blazed the trail.  But where Freestyle Libre is taking CGM seems like widening the trail so more of us can take advantage of this real innovation.  Bravo, Abbott.


What Makes Me Cranky?

Truly, I’m not ALWAYS cranky. But there are some things that spin up my Vex-o-meter. If you are a diabetic – T1 or T2 who uses insulin – you’ll grok this immediately.

I’m happy any time the FDA turns its turns its attention to generics with an eye toward increasing competition, simply because eventually that will lead to moving faster with biosimilars, and eventually maybe this will mean more attention to biosimilar insulin, which in turn might give us some relief from the astronomical price of “brand name” insulin.

Don’t get me wrong; I’m a 100 percent (or close) fan of Lilly, Novo and Sanofi for delivering us some very cool insulins over the past few decades. Would you really like to go back to the days of “R” insulin, which was “Rapid” only if you ignored the 30 minute – plus or minus – variance in time to peak action? But the truly fast (and consistent) insulins – lispro and aspart – have been around since 1996.  Their attributes have scarcely changed, yet they are what,  . . . triple (quadruple) the price they were when they first came out?  C’mon, those pen injection devices can’t cost THAT much.

For Type 1’s, this isn’t an optional exercise. We didn’t choose to become diabetic, but we’re kind of stuck with it. And, either we take insulin on a regular, daily basis, or we go the way of diabetics in pre-Banting era . . . that is, once you were diagnosed, it was a death sentence.

So, would I like to see FDA promote more competition? Yes. And good for you, Scott Gottlieb, for putting this on the agenda.

Would I like to see someone develop a biosimilar of the fast-acting insulin? Yes. Anything that drives the price down (assuming safety equivalence, of course) would be welcome for those of us who inject multiple times a day (or must change their pump sets regularly).

Didn’t think this would be the content of my first post, but it’s been on my mind and it’s always timely.

Crank out.