It is not suprising that with the aquisition of disease status, that some
patients could develop defence mechanisms to counter the feeling of loss of
control as a result of diabetes.

It may be possible using the Health Belief Model and Cognitive Model to
examine the rationale for this patient's acquired fears. Often simply by
giving information pertinent to the patient's concerns is sufficient for
them to draw their own (and sensible) conclusions. There is no evidence that
in the use of mixed insulins (in a stable insulin-treated patient) requires
qds monitoring. Infact attempting to titrate mixed insulins to 'snap-shot'
blood sugars could deteriorate good control. A trend in blood sugars over
24-48h is a more accurate reflection of control unless the patient is
unwell. 

In patients using a basal bolus regime with pre-meal rapid-acting insulins,
there may be a need to check blood sugars in order to titrate against a
meal, but even then, most learn to accurately estimate their requirements.

If all else fails, it may be worth suggesting they consult the BDA (local
branch) to verify your advice!

CK Khong
[log in to unmask]

> ----------
> From: 	John King[SMTP:[log in to unmask]]
> Reply To: 	[log in to unmask]
> Sent: 	23 November 1998 21:15
> To: 	[log in to unmask]
> Subject: 	Diabetes test strips
> 
> In article <[log in to unmask]>,
> Roger Leary <[log in to unmask]> writes
> >Advice and feedback please!
> >In a similar vein Our practice has a new patient who is diabetic. He
> >self tests blood glucose 7 -8  x daily.
> This would only be reasonable if he was one of the very small minority
> who have unstable diabetes with no warning whatsoever of hypoglycaemic
> attacks. Otherwise, it is wholly inappropriate, whatever the strips
> cost.
> 
> > His previous GP supplied him
> >with 10 cans of testing strips (50 per can) every 8 weeks (cost approx.
> >25ukp per can) and he has expected us to do the same.
> It would probably be helpful to speak to his previous GP to see how this
> situation arose. It seems unlikely that any GP would suggest such a
> regime. It probably arose by default, or from the patient's
> interpretation of what was said (I am often surprising to find out what
> patients' have derived from advice given by myself and other partners
> within our practice, the notes often showing different advice).
> I've just picked up a patient who has been testing 4 x daily since the
> summer. The excessive usage only came to light when she requested that
> her repeat prescription be increased to 4 x the usual amount. She told
> the receptionist that her new meter is just so easy to use!
> 
> >  We have
> >challenged his use pointing out 3-4 x daily testing would be ample and
> >reducing his script to 4 cans.
> Once daily (differing times) should be ample in a stable patient.
> 
> > He wrote a very strong letter saying we
> >would be responsible for a deterioration in the tight control targets he
> >set for himself and demanding reinstatement of his 10 cans.
> Is he on a sliding scale?!
> 
> >Clearly he is a very obsessive individual who feels his use justified.
> A flippant remark would be that even using 60mg Paroxetine daily to
> treat his possible Obsessive Compulsive Disorder would probably reduce
> your drug budget over a 12 month period!
> >
> >What should we do.  Do people feel we would be justified advising him
> >that if he wishes to test himself this frequently he will have to fund
> >the additional cans over and above 3-4 test strips per day himself? Can
> >we legally do that.
> I should think so, as long as your management was seen to be reasonable.
> My patient hasn't come in yet (someone else who doesn't see the need to
> attend our diabetes clinic), but I am going to offer 50 test strips for
> 28 days (with appropriate explanations).
> 
> > Clearly persuading him that his frequent testing is
> >of little benefit would be best
> I have found that the Community Diabetes Specialist Nurses are
> invaluable in difficult management situations. The main problem here is
> one of education and they seem to be skilled in putting the message
> across and following it through (an HbA1c now and 2 months into any
> agreed change of management would be helpful).
> -- 
> Dr John M King
> GP North Staffordshire
> 


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