Search for tag: "type 2 diabetes"

Dr. Jones: Diabetes and the bladder, you never think of these two things going hand in hand. You think of a cupcake and diabetes, not the bladder and diabetes, but today we're talking about diabetes, the bladder. This is Dr. Kirtly Jones and this is The Scope.

Here in The Scope studio, we have Dr. Sara Lenherr, who is a urologist by training, but subspecialty trained in neurology. Today we're talking about diabetes because diabetes is a complex disease. It affects every part of the body and the bladder is the final common pathway of both nerves and sugar and trouble. Welcome to The Scope, Sara.

Dr. Lenherr: Thank you for having me.

Dr. Jones: I think in my own practice sometimes I diagnose diabetes because of women's urinary frequency. So can you tell us a little bit about how the first signs of diabetes might affect the bladder?

Dr. Lenherr: Sometimes women with poorly controlled diabetes end up having a bladder that spasms too frequently, and that can be very bothersome. It makes them feel like they have to go more frequently and urgently.

Dr. Jones: Also, sometimes people who don't know they have diabetes yet, their sugars are high, the kidney is trying to dilute that sugar, and they just pee a lot.

Dr. Lenherr: Yes, frequently these patients make too much urine because their kidney function is affected, and so they just make more urine than the bladder can handle, and it makes them feel like they need to go more frequently, and they do.

Dr. Jones: So peeing a lot in large volumes, for me, I remember that from medical school, was you better make sure they don't have diabetes.

Dr. Lenherr: Exactly.

Dr. Jones: Over the long term, though, diabetes affects your nerves in your feet and affects other parts of your brain, but talk about the bladder in long-term diabetes.

Dr. Lenherr: Diabetes in patients that have had it for a long time can affect the fingers and toes, and all that sensation also affects all of the nerves that go to the bladder, and so the bladder doesn't necessarily contract at the right time. Either it's overactive, or it's underactive. It doesn't contract well enough, and so therefore it doesn't squeeze when you want it to and you don't empty your bladder completely.

Dr. Jones: So in terms of diabetes, we certainly want people to be in good control, because that might help early on a lot of their bladder symptoms, meaning if their sugars are in good shape, their bladder will probably be in good shape. But for people who have been diabetic for a long time and they weren't in such great control and now they have more permanent damage, how do you make that diagnosis?

Dr. Lenherr: Usually, we check and see whether or not the bladder empties completely, so once you go, we can then check and see if you have a residual left over in your bladder, and then we can also check bladder function tests where we measure the pressures inside the bladder and see how your bladder behaves with filling and then trying to empty your bladder.

Dr. Jones: Is that very comfortable? Reassure me that that's not going to be a painful test.

Dr. Lenherr: It's a very simple test that's done in the office. We put a very small catheter that's smaller than the mouse cord that goes to your computer, and we place that inside your bladder, and we place also a very similar small one inside the rectum. This helps us look at how the bladder behaves with filling and emptying to measure those pressures and see whether or not your bladder nerves are not working properly.

Dr. Jones: Okay, maybe I would have this test. Okay, I'll have this test. So, I had this test and my bladder isn't contracting very well. What are you going to do? What can you do to help me with this?

Dr. Lenherr: Depending on how much your bladder is injured, sometimes we have to have patients actually just pass a small catheter every four hours while they're awake to empty their bladder as opposed to trying to pee it out. But if you have a little bit of bladder function, then sometimes we can actually give you a bladder pacemaker that helps your bladder contract in a much more efficient manner, and therefore you're able to empty without having to use that catheter.

Dr. Jones: How about as people get older? I think of the elderly patient with what we call comorbidity, so they're older, they have diabetes, they have heart disease because it's affected their heart, maybe they had a stroke. Urinary incontinence is the number one reason to be admitted to a nursing home. So what do we do for older people? Can they do their own catheterizations, or is this something a family can help them with?

Dr. Lenherr: The complex patient with incontinence is definitely some of the more challenging cases that we have, and it's a balance between figuring out what the goals of care are. Some patients are very happy to have family help them catheterize if they need that to be done. Sometimes patients would rather not have their family members be going down there and helping them pass a catheter, and depending on how the bladder works, it can be a very good option to leave a chronic catheter in place.

Usually we try to place that in a suprapubic location, so right above the pubic bone below the belly button, and that helps drain the bladder and improves quality of life in a lot of patients. But these are really specialized conversations that we have with both the patients and their families to determine who is going to help out the patient and who is going to be able to help keep the patient safe and happy.

Some of the more rewarding conversations are having these discussions where you have patients understand these are my choices and this is what my goals of care are, and it's not always a quick fix, and it's not always the most complicated solution. Sometimes it just needs to be something simple that everyone agrees this is what I want to have my life be like, and I'm there to offer those solutions for them.

updated: November 24, 2021
originally published: December 23, 2015

Interviewer: Is there a pharmacist in the house? Making the case for pharmacists in a primary care setting. Up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The science and Research Show is on The Scope.

Interviewer: Most people don't think of pharmacists as being involved with primary care at the clinic, but Dr. Carrie McAdam-Marx thinks that needs to change. She's the Associate Professor of Pharmacotherapy at the University of Utah. So you make the case that having a pharmacist in the primary care setting is not only better for the patient, but it also makes economic sense. And you did some research looking at that. Can you talk about that a little bit?

Dr. McAdam-Marx: We took a group of patients that had been treated in a primary care clinic that had access to a clinical pharmacist and these pharmacists were specifically focusing on patients with diabetes, type II diabetes. Patients with diabetes are on a lot of medications and, unfortunately, the average patient with type II diabetes is not optimally controlled. So we had approximately 300 patients that had been followed by a clinical pharmacist in the primary care setting and we compared those to about 400 patients in clinics that didn't have access to a pharmacist at that time.

It's a service that's evolving in our University of Utah community clinic is at this point. We looked at how their diabetes is controlled, we looked at their diabetes control over time, being followed by the pharmacist, but we also looked at their cost, their total cost of care from the perspective of the University of Utah Health System.

And both our intervention patients, those who saw the pharmacist and our comparison patients, saw an increase in cost over time, which isn't necessarily unexpected. They're older patients, they have complex health conditions and their costs are naturally going to tend to go up. But what we saw was that the patients who were followed by the pharmacist had a much slower increase in cost than those who were not.

Interviewer: So over time, how much time were you looking at?

Dr. McAdam-Marx: We followed these patients for a year.

Interviewer: And differences in cost, how much of a difference?

Dr. McAdam-Marx: So in the comparison patients, their cost went up over that year, they were higher in the year after our baseline period by about $1200 per year. And then the comparison patients were closer to $200 increase per year.

Interviewer: Oh, wow.

Dr. McAdam-Marx: So it was substantial. It's difficult, in a short period of time, in a chronic disease to show an improvement like this so we were really excited with the results.

Interviewer: So they just had fewer complications or what was the reflection? What was the lower cost due to?

Dr. McAdam-Marx: We looked at total cost, so all of their outpatient costs and inpatient cost, emergency visit costs. What we found is that these patients used more primary care services. They were going in and having follow-up visits with their primary care provider. So that area was going up, but we saw a substantial decrease in other areas. So fewer needs to go see specialists and slightly lower costs in terms of inpatient and emergency room costs.

Interviewer: So what happens if a pharmacist is not involved in decision-making at the primary care clinic? What's an example of what can go wrong or how they can make things go better?

Dr. McAdam-Marx: As patients being treated by primary care doctors become more and more complex, more chronic diseases, multiple chronic diseases, they're on a multitude of medications, oftentimes. Sometimes these medications can interact or counteract each other and having a pharmacist on the team who that's what they're trained to do, to optimize drug therapy, can play a huge role in that team-based care.

They provide input and guidance to the primary care providers on what are the most optimal drug therapies for a given patient and so, when a patient has the opportunity to meet with a pharmacist and have a pharmacist review their drug therapy, there are often times opportunities to change doses, add medications or remove medications with the goal of helping that patient achieve the treatment goals that they're after: better disease control, fewer side effects in a more efficient and a more effective manner than might happen otherwise.

Interviewer: So do you find that patients are open to this idea of working with a pharmacist as a primary healthcare provider? I mean, we're used to thinking of well, at least me, maybe it's my bias, I'm used to thinking of going to Walgreens and talking to the person behind the glass window and getting my medications that way. It's sort of a conceptual shift for people. Are they ready for that?

Dr. McAdam-Marx: It's my impression that they ar. To clarify, I'm a researcher so I'm actually not the one delivering this care. But I have a team of very excellent clinical pharmacists and their response is yes, definitely. They appreciate that their primary care provider is busy and they have a limited amount of time. Often times, they will meet with the pharmacist before the physician comes into the room and they can have an extended conversation about their medications, what they're experiencing, how things are working. I think they recognize the pharmacists as the drug experts.

And keep in mind that many of these patients are older and they grew up in the day of independent pharmacy, they call the pharmacist "Doc," they had a very personal relationship with them. So for them to transition that personal relationship out of the pharmacy and into the clinic, it was probably less of a shift than what we might think otherwise.

Interviewer: Great. Is there anything else you want to make sure to add?

Dr. McAdam-Marx: I'm excited to see the evolution of clinical pharmacy in the primary care setting and the growth in the profession itself. Pharmacists are trained specifically on drug knowledge and having that opportunity to carry that knowledge into the primary care setting, where, quite honestly, a lot of our care is delivered is really going to be very beneficial for patients, to providers, to payers, to the healthcare system. So I think it is going to be a win-win-win for everyone that's involved.

Interviewer: Interesting, informative and all in the name of better health. This is The Scope Health Sciences Radio.