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Question.
I
seem to have a dilemma with rising levels of my blood sugar; perhaps you
can shed some light?
Several
years (4) ago I was diagnosed as having Type II Adult Onset Non-Insulin
Dependent Diabetes. My physician started me on a product called Amaryl
and told me to return to the office in one month. A month later when I
returned to the office everything was fine. My blood sugar was in a range
that my doctor liked so I was told to return just twice a year.
However, after a year had passed my blood sugar levels were found to be
abnormal again. Now my doctor ordered a second agent, metformin or Glucophage
- 500mg twice daily. At this time my doctor also advised me about a medical
device that would allow me to monitor my blood sugar at home - Lifescan.
Six months later my blood sugar was still not controlled so the doctor
stopped the Glucophage and started Avandia. I continued to monitor my
blood sugar but for some reason the levels remained high and were not
to my doctor's liking. So my doctor now ordered a long acting insulin
to be used daily and regular insulin for those times when my blood sugar
reached certain predetermined levels. He called this a sliding scale for
using the regular insulin. He did not discontinue the Amaryl or the Avandia.
Incidentally, I walk daily and work out with weights every other day.
Regardless of the intervention employed to date, my fasting blood sugar
has not been be below 160 for some time. In fact the average daily fasting
blood sugar level seems to be steadily rising over these last 3 years.
Occasionally when I have had to use the sliding scale with the regular
insulin my blood sugar has dropped severely into the low 50's and even
40's on one occasion.
What is going on?
DW Solvang
Answer.
Life
is so complex and so is the management of diabetes; whether or not you
have the non-insulin dependent type or the insulin dependent kind. As
our knowledge grows so does our understanding.
We now know that using members from the family of second generation sulfonylureas,
like Amaryl, by themselves to treat non-insulin dependent Type II diabetes
may not good in the long run. Basically these agents stimulate the pancreas
to release insulin. Unfortunately over the long haul and in susceptible
people, this almost constant stimulation of the pancreas by these agents
can literally wear out the pancreas and generally leads to insulin dependency.
Additionally, it appears that the dose of these products may have to be
continuously increased to produce the desired results. Sometimes the dose
of these products cannot be increased owing to intervening side effects.
Avandia, a member of the family of medications called "glitazones." These
products are designed to increase the sensitivity of your body's muscle
and liver cells to circulating insulin or reduce the resistance of the
body's muscles and liver to circulating insulin. Thus, what insulin is
present in your body will work more efficiently. Generally speaking members
in this family are used in combination with either a second generation
sulfonylurea like Amaryl or with metformin. At this point the story gets
fuzzy.
We also have learned, in the last 3 years, that there seems to be a critical
level for a two hour after meals circulating blood sugar that activates
the liver to release more glucose or sugar into the blood. Below this
level the liver rests and stops putting sugar into the system. One level
I have read is that your circulating, two hour after meals, blood sugar
levels should be below 140 particularly in the evening for your liver
to rest or stop putting out glucose (sugar) into your blood. Metformin
works exclusively on the liver to reduce liver or hepatic production of
glucose. Metformin does not impact the pancreas like the sulfonylureas
and in fasting non-diabetic individuals it does not cause hypoglycemia.
There is also evidence to suggest that individuals who use metformin experience
a modest 5-10% weight loss over time.
The active therapeutic dose of metformin found to be effective in most
people is higher than what your doctor had prescribed for you. Evidence
suggests that in many, the therapeutic dose may be closer to 1,500mg per
day in divided doses. Perhaps another trial would be warranted. I would
speak with my physician about this approach.
Finally, while speaking to your doctor about another possible trial with
metformin you may want to speak with your doctor about why you are still
receiving two oral agents and insulin as well. Perhaps it is time to consider
some major changes in your therapy since you state that over the last
2-3 years your average daily fasting blood sugar is steadily rising.
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