Hi y’all,
I’m coming over just to vent some frustration. I am a type 1 (like my grandfathers) but my mom is a type 2, and I highly suspect my brother has become a type 2 as well, however, his doctor is extremely resistant to a diagnosis of anything more than prediabetes.
His A1C is 6.4 on 500 mg of metformin, fasting blood sugars consistently over 140. His doctor only prescribes 1 test per day, because he says he doesn’t need anymore than that. He also was very resistant to doing any testing to confirm he was type 2 until last week when I have my brother a script to follow. His tests came back with an insulin level of 24.5 at fasting (I’m not sure what his fasting glucose was, he seems to think it was around 130). He isn’t breaking 200 yet, but consistently around 140-180 until right before supper when all of his walking from work kicks in (he is in security at a hospital) and only knows this because he bought a Walmart meter and strips. Still waiting on antibodies, but I doubt he’ll have them.
His current primary care doc refuses to give him a referral to an endo (which my endo suggested due to family history) because “PCPs are trained to treat Type 2”. But, if that’s the case, why isn’t he treating him?!? My brother has changed his eating habits dramatically, takes his metformin, and the numbers just keep climbing. He has asthma, so I worry about complications being magnified because he doesn’t get good oxygenation anyway. I’m doing everything I can to help him, but without his doctor’s cooperation it becomes a moot point. My brother is hesitant to switch PCPs because of all of his medical history and it takes a lot of time to get a new one up to speed.
So here is what I have him doing. He is keeping a log with carb counts and pre/post meal glucose, plus fasting and an overnight reading once a week (he has serious DP going on). He checks randomly when he feels bad and writes down his glucose and his symptoms. He keeps track of how many steps he takes in a day. The plan is to hand this over to the doctor at his next visit, with a request to properly treat his glucose, rather than a request for a diagnosis. I hope it works and doesn’t make him angry, but having the complications and rate of diagnosis in our family, I honestly don’t care, and I don’t think my brother cares anymore either. I kind of like my stinky kid brothers, so I want them to stick around and be healthy. I think this is magnified by my Dad having ALS, after years and years of being healthy as a horse, so damn it, if we can prevent a stupid illness we are going to.
Thanks for reading. If you have any advise I (and my brother) would appreciate it. 
Your stinky kid brothers are lucky to have you as a sister. I’d do exactly what you are advising your brother to do, but test and log even more often. After his PCP is presented with the data, if a referral to an endo isn’t forthcoming, I’d get a new PCP.
Thanks. I’ve spent years and years advocating for my mom’s health (it saved her life once), so I’m getting pretty good at it. I have the utmost respect for medical professionals, but not blind trust which seems to be what this PCP wants from him. My doctors are used to this, so it drives me crazy when his doctor is fighting this dx so hard and the signs are right there, just because of a measly .1 on an A1C.
What other times would you suggest to test?
RE testing, I’m thinking daily AM fasting, before each meal, and two hours after each meal, and right before going to bed. I know it’s a lot more than your brother has been doing, but he needs a formidable “paper trail” to assist in his (and your) efforts to get the care he needs and deserves.
I have a patient whose PCP blew off his consistent fasting BGs in the 130s to 150s for well over a year, despite my polite requests to treat our patient with Metformin (or something for heaven’s sake!) before I started doing it myself (I do not specialize in Endocrinology). What finally got the PCP to move his arse was my printing up the diagnostic criteria for D and giving it to the patient to present to his PCP along with a small mention about the fact that I was documenting his lack of D-care.
Another patient: Type 2, inadequate follow up by her PCP, with crappy A1c’s and clearly a need for a higher Metformin dose. A very polite and respectful telephone call to her PCP requesting he consider increasing her Metformin dose was met with the comment “And just how many cases of Type 2 have you managed compared to me?” Took all I had to bite my tongue (a little bleeding occurred) and say “Look, I think we both want the same thing: what’s best for the patient, right?” (I called him an asshat [and worse] after I hung up the phone. Made me feel better.)
Fortunately, faxing lab results (I order a lot of fasting plasma glucoses and A1c’s) to a patient’s PCP with abnormal values heavily circled with my initials and a notation that I’ve made the patient’s PCP aware of said results gets a positive response in over approximately 65% (a gross estimate on my part) of cases. When it doesn’t, I get politely aggressive. Fine if they want to label me a pushy beotch. Don’t necessarily like the label, but I do what needs to be done.
Rose’s advice is right on the money, all of it. Now, as for me . . .
< rant>
I hate, hate, hate the term “prediabetes”. I’ve railed against it at length elsewhere, so rather than repeat that whole argument I will just say this: your brother has diabetes. (A very mild case to be sure, and mega kudos to you for your determination to keep it that way). I will maintain forever and to anyone that there is no such thing as prediabetes. Either your body can control its blood sugar, alone and unassisted, or it can’t.
< /rant>
Agreed! I hate that term so much!
Part of the reason I am so, so insistent is that we are heading into his prime breathing trouble/cold season. He is on prednisone at least twice a winter, and while his bgs are not as elevated as they could be right now, steroids are an instant DKA trigger for me (I can’t control my glucose at all on steroids) and my mom tends to get into the 400s to 500s without insulin when she takes them. Her numbers outside of when she takes prednisone are better than his, so I worry.
I realize I was unclear… He tests everything except the overnight one every day. So exactly what you recommended. I’m glad we are doing it right. 
Steroids (other than topical ones) are a BG spikemaker for almost everyone. Varies by degree, of course, like most things. But they’re a pretty dependable trigger.
Ah, the good old days! In late 1960’s, as a nursing student, my annual lab tests consistently showed glycosuria, with follow-up FBS consistently normal. This persisted over several years until I self-referred to an endocrinologist and had a 5 hour glucose tolerance test that peaked at 400 mg/dl! Since FBS was normal, I was termed “pre-diabetic” and told to avoid heavy sugar loads (like 5 hour GTTs!).
I’m sure it was the times, before A1c, meters, pumps–even the oral meds we have today (does anyone remember Orinase?). Pre-meal sugars were tested on urine!
Check the age and Continuing Ed credits of docs using the “pre-diabetic” label!
I agree—test a lot. And also help him to figure out how to moderate his carb intake in a way that he can actually sustain—not always easy, I know…
Also look at social factors for their emotional impact…Is he subject to loneliness or isolation? Does he have a decent support network that could maybe have fun learning yummy low-carb recipes with him?..Etc…
He has a pretty good support system, however, my sister in law hasn’t figured out that pasta, rice, and potatoes will never be low carb.
The diagnostic criteria from the AACE says that if your fasting blood sugar is > 126 mg/dl that alone is sufficient to diagnose overt diabetes. You can bring this clinical practice guideline in and demand to get that standard of care, but I have to be honest, even if you get that standard it doesn’t mean the PCP (or another doctor) will consider increasing treatment as the goal is HbA1c < 6.5% (including the AACE treatment management algorithm). The important advantage of the AACE approach is that it explicitly call out to have patients normalize their blood sugars as much as possible. The ADA/EASD approach is instead to try to keep patients at an A1c of 7%. The key advantage in getting an overt T2 diagnosis is that insurance will provide better coverage for things like test strips.
ps. 500 mg of metformin is unlikely to do anything, most of what I have read suggests that most people need at least 1000 mg before it kicks in.
I have read that as well on the Metformin. He takes it at night, and it isn’t doing anything (it’s not extended release). I’m hoping the logs will help show that.
I’m hoping he will go to my endo. She’s pretty feisty about getting him in to see someone, and really thinks she could help him get his A1C down. I really couldn’t have found a better Endo office for myself, and I’d love for him to get the same quality care.