Are any of you on 3 or more oral medications plus long-acting insulin? My mom, a type 2 for about 15 years, just got her latest A1c back. It was, yet again, 8.2. Her family dr has her on Gilpizide, Metformin, Januvia, and Lantus. Now, he wants to put her on Prandin (repaglinide). Her A1c hasn't been below 7.5 in well over a year, she's on the max dose of all of the oral drugs (and he wants to put her on the max dose of Prandin as well) and he intensified her Lantus dose from 10 units to 12 units/day. I think she's on enough medications and her A1c is high enough to warrant starting MDI. I convinced her to ask her doctor for a referral to an endocrinologist (Thank goodness; she finally has agreed!), but whether the doctor will make the referral remains to be seen. Are there any out there who are in the same position she's in? I'd really like to know if others have had the same experiences.
Not oral hypoglycemic agents for me, I'm T1, but I'm on Synthroid (thyroid), Lisinopril-HCTZ (blood pressure and ACE inhibitor), and Lipitor pills.
I've done some research and think Metformin has obvious advantages to a T2, even with insulin. 12 units a day of Lantus is pretty small dose, but many non-endos are very overly cautious with insulin out of fear of hypos, and I think that's where your mom's doc is, he's so afraid of upping insulin dose that he'd rather prescribe more pills.
An endo might be similarly cautious if the patient is not already doing multiple bg checks every day at home. More intensive insulin treatment on basis of A1C is not going to work, will require multiple bg tests every day, for some that's a "deal-breaker".
It is time your mum saw an endo, triple therapy seems the norm before basal/bolus.. here is a US endo chart that indicates treatment plans.
https://www.aace.com/files/aace_algorithm.pdf
If I was your mum, I would find another Dr who is able to handle her diabetes better, because when she progresses to basal/bolus she will need frequent advice and monitoring
also in my opinion, if not already, a low carb diet would benefit
She was having hypos on a mere 10 units of Levemir, which is why she stopped that for a short while. When her A1c went out-of-control again, the doc prescribed Lantus. It did bring her A1c down from nearly 9 to the 7.8-8.2 it's been, but it hasn't brought it down any further. I think the reluctance to increase the dose of Lantus is that (a) he wants to avoid further weight gain (she's been angry at him since he put her on Actos and she gained about 30 or so pounds within a few months) and (b) he wants to avoid hypos.
She's already on Metformin and she hates it. Has hated it since she started it back in 2002 or 2003 (I forget when, exactly). It caused her to have stomach problems when she started it and she's convinced that her current problems with her stomach are exacerbated by the Metformin. The doctor she's seen for her stomach problems and who does her colonoscopy says she has diverticulitis and she thinks the fact the Metformin ER pills shells stick around in her intestines until like, 2 weeks worth of them are expelled at once doesn't help her any.
She'll test more than once a day, if she's given a reason why she needs to do it and if she's given some idea of what to do with the numbers, other than just "Write them down and give them to me when you come to the office next time."
Damn, but I hate the way GPs and even endos treat type 2s. :( Frackin' ridiculous.
Yeah, I've been preaching the AACE algorithm and consensus statements for a long time. We talked about that, and it's what's convinced her that piling on yet another pill isn't going to help.
She's not adverse to more frequent monitoring, nor is she adverse to seeing an endo. She's a bit wary about seeing a CDE, because the CDE/dietitian she saw with her husband was next to worthless. Pulled out the stupid plastic foods and essentially threw a pre-printed 1800 calorie diet at a 6 foot, 200+ lb man without bothering to determine how much he was eating, what his preferences are, etc. It was a total waste of time and she's afraid of having the same thing happen again.
As for the low-carb diet, well, she has diverticulitis and has been told she needs to increase her fiber intake in order to "keep things moving", so to speak. So far, most higher fiber, low carb veggies, like cabbages and Brussels sprouts, tend to cause her to have the attacks. A diet that's full of high fat, high protein foods and little-to-no fiber is one that's likely to slow down her digestion even more and cause more inflammation and infection (thus even Atkins' recommendation that people supplement their low-carb diets with fiber supplements and Bernstein's reluctance to work with people who have gastroparesis). So, I'm not so sure she will go for that. I think if she had some decent education, had her c-peptide levels tested, and had a doctor who actually knew the AACE recommendations, she'd be in better shape.
A stepped-up insulin regime with fewer oral hypoglycemics is very possible but will require education of your mom, to a level probably way above her current doc's expertise. Intensive insulin treatment, some of us have been doing it for a big chunk of a century, it really is the appropriate standard of care, but only a tiny fraction of the medical establishment is experienced with it.
I was on triple medications for about two years. My general opinion is that while a medication like metformin may have an effectiveness that may drop your A1c by 1%, when you combine medications you get diminishing returns. And unfortunately doctors use a treat to fail approach, running through every possible combination of combination of medications and then when you don't reach an A1c of 7% they change around the medications. Only when things get really, really, really bad do they give you insulin. The whole thing drove me so crazy I just took the issue into my own hands and started insulin on my own. So my message is that once you fail on triple medication it is time to consider a move to insulin.
So my view is adding a fourth drug will at best drop her A1c by 0.1% and simply put off the decision. Your mother has a right to good health care. By any standard of practice she should be moved to insulin therapy. And using only a basal insulin is an obvious recipe for hypos between meals. Unfortunately many GPs are really insulin resistant to initiating insulin therapy since there are risk such as hypos and adverse consequences can be directly tracked back to the decision to start insulin. My solution was to simply take the decision out of the doctors hands. It is after all really your mom's decision.
A few comments:
- As a T2, it's very likely she has insulin resistance. Assuming she does, 12 units of lantus per day is a waste of time, and is not really doing much of anything. Given her hostory with this disease, how long she's had it, the treatments you've described and her a1c, I suspect she has an insulin-to-carb ratio in the 1:4 - 1:7 range. Also, she clearly has some functional beta cells, so this low-level of insulin most likely is simple replacing basal excretion by the pancreas, thereby doing absolutely nothing at all.
If my assumptions here are correct, or even roughly close, she would need more like 20-40U of lantus a day to have any impact on consistently lowering BG, and therefore a1c. The problem is, to use this treatment effectively adds a very real risk of hypoglycemia episodes if eating plans (meals and snacks) aren't followed, and BG isn't checked frequently.
- With Glipizide and Januvia in the mix, and control still not being achieved, this implies a nearly exhausted pancreas that has essentially failed completely for all practical purposes. Assuming she's not habitually overdoing it on the other side (eating carbs), the only way she can hope to succeed with this treatment approach is to adopt a very low carb diet (probably less than 50-80g carb a day, spread out over 3 meals and 2-3 snacks). A lot of people are very successful and happy with low or no carb diets -- we have members here doing well with that approach. However, it certainly mean giving up a wide spectrum of foods that simply isn't acceptable from a life-happiness POV for some (like me). Regardless, I still try to go "moderate carb" most of the time, keeping it to around 100g a day, with the occasional splurge.
I've learned, though, the hard way, that Oreos are Satan's Spawn forged in the demon fires of hell. 25g EACH. Just thought I'd pass that on :-)
- You'll find a very solid opinion around here that pancreatic stims, like Sulfonylureas (glipizide is one) and others, are frown upon rather strongly. There is both anecdotal and some solid scientific data that strongly suggests they just accelerate the process of causing the pancreas to completely fail.
- I'm a T2. My situation, in terms of the "state" of my disease is very similar to your mom. The best thing I did for my health, happiness, vigor, etc. was dumping all those pills (excect metformin) and start MDI. I talked my endo into a pump and CGM, and now I'm a tight tight tight controller. My last a1c was 5.8. Had my regular weekly Double Double treat for lunch at In-n-Out today, administered Humalog (fast-acting insulin) perfectly (pre-bolus timing, square-wave over the next 3.5 hours), bg started at 85, peaked at 127 about 2 hours after eating, back down in the 90s after 4 hours. That's control, baby! It can be done, but I'm afraid the only way to do it at this point in her progression is with MDI, and that would be bolus insulin. This, paradoxically, may be all she needs -- without basal insulin (Lantus).
- HOWEVER... truly effectively treating this disease is involved. Getting healthy a1c's requires a lot of attentiveness, planning, self-education, etc. The pop pills and forget about it route only works for a relatively short time, and the disease progresses. It is very much worth it, though!
she thinks the fact the Metformin ER pills shells stick around in her intestines???
The metformin I take is not a capsule, but rather a typical compressed-powder pill that dissolves into mush when hydrated.
At the very least getting her on a different physical form of the drug could eliminate this issue, so the diabetes and stomach issues can be addressed without conflation.
The main thing for now is the endo,to get your mums BG right, any diet tweeks can be done later
I found my symptoms are very much reduced when I reduced carbs. she may need to reduce her starch carbs, not her fibre carbs, I forgot the US includes them together as a total.
I didn't do high protein, the excess only converts to glucose and isn't the jury is still out on if it's good for the kidney?
I didn't need to increase fats, I had enough fats, when the carbs were reduced to be classed LCHF. I swaped the grain oils/fats for olive oil and butter, they say is a good thing too
Well, just like you have some distrust of the CDE/dietician thing you probably should have some distrust of the whole fiber cures diverticulitis thing. There is debate in the medical community about the lack of evidence for the relationship between low fiber diets and diverticulitis. Some people believe it is really about gut flora imbalances and inflammation. It may be worth experimenting to find low carb foods that your mother can tolerate. Brussels sprouts and cabbages are from the same family and your mother may not tolerate them, but other low carb veggies may be wonderful.
Interestingly, I read that diabetics have 'different' gut flora than their peers, it will be interesting to see where this research goes.
http://articles.mercola.com/sites/articles/archive/2010/03/02/diabetes-alert-your-gut-microflora-may-be-out-of-balance.aspx
You are doing very well on the pump, 5.8% without frequent hypo is as good as anyone would want.
I think the lantus is a background insulin and may cause problems if it is increased to try and cover food glucose.
It could be that an addition of a bolus insulin may be more appropriate for food glucose I:C Perhaps a shift to a mixed basal/bolus insulin? Like NovoMix 30 or similar as a next step?
And unfortunately doctors use a treat to fail approach
Brian, I have to say that the tone of this statement bothered me, the more I thought about it.
Of course that's the approach doctors take. It's the right approach. If a treatment is working, the goal has been met, has it not? It's not until it fails that somethings else is required.
I think it a bit unfair to criticize doctors for the common and sensible approach of trying different treatments until something works. This is not like changing oil in a car -- there is so much variation from person to person physiologically, and psychologically, that none of this is formulaic. Something works? That's good, right?
Confounding that is no particular treatment regimen can be said to be the "right" regimen, the "best", or the "healthiest" for all diabetics.
So, I would urge you to reconsider your view that this is "unfortunate". I'd say, rather, it's a very good thing, as in the end more diabetics get treatment and improved outcomes than otherwise.
If it were up to me, I'd have every T2 start on bolus insulin at diagnosis. As we know, this is what Joslin is recommending these days. Problem is, most T2's disagree :-)
you are right, the other side of the coin is that, it's also up to the patient, sometimes they refuse or resist moving to other treatment and meds, even when offered. that doesn't mean the Dr. just lets them go, sometimes counseling is in order
as you said there is good evidence for saving beta cells with insulin by good BG control. It seems diet/lypotoxicity is important for long term success as well
http://www.diabetesincontrol.com/articles/54-/11534-early-use-of-in...
there is also good initial evidence for reversing/remission with normal pancreas response with a 800 cal diet for 8+ weeks. Imitating the post bariatric surgery diet. They are currently funded for a further 5 year trial
http://www.ncl.ac.uk/magres/research/diabetes/reversal.htm
I appreciate your thoughts. I didn't coin the term, Ralph DeFronzo did. And when the ADA/EASD came out again with their a repeat of their stepwise medication algorithm there were many criticisms such as those from DeFronzo. I still think the term is appropriate. DeFronzo and others argue that the stepwise treatment keeps the T2 patient at 7% or higher for years by a constant changing rotation of medications which are not durable and increasingly do little to reduce blood sugars. This is why I call it "treat to fail" because the treatment target is to make sure the patient maintains an A1c of 7% or higher. As a patient I was made to feel that the only way I could get insulin was by demonstrating complete and utter failure of blood sugar control.
DeFronzo's recommendation is to start with the most effective oral combination treatment and once that fails admit that further rotations and changes are unlikely to lead to any improvement. At this point the patient should just move to insulin.
Put in that light, I feel very different about the comment. To quote one of my favorite philosophers:
Sorry if I came of strong. I just feel like we shouldn't feel like we move to insulin because we have failed. That is just wrong.
I'm like Brian I was on a triple drug regime for a while and was never happy. The treat to failure approach always kept me on the verge of failure, not a place I wanted to be. Eventually you got to quit beating a dead horse.
I'm not saying that a full blown MDI insulin regime is the best for your mom, but I do know that it was best for me. I have never felt that moving on to insulin meant a failure on my part. I was doing what was best to fight this disease. I did not fail I continued the fight.
There's some good news on that front: Her family doctor didn't fight her for this referral. Thank Goodness! He said he was trying to avoid having to add rapid acting insulin to her medication load. Yeah, just add a pill you have to take three times a day...with a ding-a-ling for an assistant, who, when relaying the dr's instructions how she ought to take Prandin tells my mom that she should take the drug 2 hours before she eats! Yes, you read that right: The doctor's assistant truly believed the doctor wanted her to wait 2 full hours after taking the drug before she ate. Since the drug is one that is meant to force a release of insulin over a short period of time, can you imagine the number of low she'd have?? Oh, never mind that the drug would be nearly out of her system by the time she would start eating! What a mess that would have been. I'm just glad I was able to convince her that she'd be much better off if she dropped this guy.
She has to call the local endocrinologists' office tomorrow. My stepfather was in the military and we were out, trying to take advantage of the Veteran's Day offers that were out there and weren't home when the doctor's offices called. So, we'll see tomorrow when she'll start seeing a new endo.