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miketurco

What med comes after metformin?

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miketurco

I'm not meeting my bg goals. Started on met 500x2, stuck with that a couple months and it helped. Then upped to 875x2 and that helped, but I'm still not where I want to be. Ideally, 100 or less. Today, which is a badday for me, I've been around 150 for most of the day.

 

So I'm wondering what generally comes after met. Glipizide?

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funkynassau

After Met I had glyburide added and that worked for a few yrs then Januvia was added to that.  I hate pills...!  In the end I had to relent and add insulin which is actually working beautifully for me.

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samuraiguy

 

 

I'm still not where I want to be. Ideally, 100 or less.

What was your last A1C? Is under 100 mg/dl what you're looking for all the time--because non-D's don't even do that--or just FBG and 2 hour PP? I would set an A1C goal for exploring other med options rather than individual BG measurements because there are so many things that can affect them.

 

As far as the next step it comes down to how much medication you ultimately want to take and dealing with their side effects versus learning to inject insulin. For me I responded well to metformin when I took it so I have no fear of adding it. I'm a "less pills" guy too so I would probably rather learn to do insulin after that if needed.

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Hooterville

Try 850 mg Met three times per day which is maximum dose. 

 

I would never ever recommend Glipizide or any other meds in that class which force your tired pancreas to produce more than it's really wanting to.   You can also experience lows with it.

 

Personally, I like the Metformin/Lantus combo.    Don't be afraid of it because it's insulin and injected.  It's a basal insulin which is long acting,   One shot per day, often at bedtime though some people do take it in the morning and some people do split it up in to two doses.   It acts as your background insulin keeping you, say, level if you didn't eat anything.  It's great for managing DP. 

 

Under 100 all day every day is an unreasonable expectation.   I'd say it's reasonable to want to be under 100 fasting but there's no reason to want to be under 100 every single minute.   Under 140 is reasonable but I always liked to stay under 120 because...well, I guess I'm not all that reasonable.    No one will prescribe Lantus for you because you want to be under 100 at all times.   Still, before adding anything else, go for max dose met.

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funkynassau

My goal is to get off the Glyburide and Januvia by this fall, which my doc thinks is doable, which would have me taking just Met and Lantus SoloStar.  I'd love to get rid of some of these pills.  I often wonder what they are doing to my insides, it can't be good.

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OldTech

Under 100 all day every day is an unreasonable expectation. 

 

Well then, I am being unreasonable! My goal is to have an A1c in the 4.2 to 4.6 range and a tight average around 83 mg/dl. This is what I consider normal blood glucose.

 

And this is exactly what Dr Bernstein recommends in order to avoid complications and to help reverse some complications. I also believe that complications clearly start in the pre-diabetic range and that any A1c over 5 can result in complications. When I was diagnosed with type II my A1c was only 6.5 (barley diabetic), yet I thought that I was dying because of the complications. Now after 6 months of an A1c of 4.9 and 4.7 most of these complications have gone or are going. 

 

I will admit that it is difficult for me to stay under 100, but I have manged to do so for days at a time (currently 6). Under 110 is easy and under 120 is easier still (I have been under 120 for months). A couple of months ago I had trouble even staying below 100 for a day.

 

I am currently experimenting with resistant starch (RS) to see if it will help. So far it seems like RS may indeed help, but I need more time to verify it. 

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jwags

When I did 850 x 2 my morning bgs were still too high. I had to beg for a higher dose. My doctor wanted to put me on a second med but I fought it. Finally my doc agreed and 3 x 850 seems to do the trick as long as I stick to LC.

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apollo322

Well then, I am being unreasonable! My goal is to have an A1c in the 4.2 to 4.6 range and a tight average around 83 mg/dl. This is what I consider normal blood glucose.

 

And this is exactly what Dr Bernstein recommends in order to avoid complications and to help reverse some complications. I also believe that complications clearly start in the pre-diabetic range and that any A1c over 5 can result in complications. When I was diagnosed with type II my A1c was only 6.5 (barley diabetic), yet I thought that I was dying because of the complications. Now after 6 months of an A1c of 4.9 and 4.7 most of these complications have gone or are going. 

 

I will admit that it is difficult for me to stay under 100, but I have manged to do so for days at a time (currently 6). Under 110 is easy and under 120 is easier still (I have been under 120 for months). A couple of months ago I had trouble even staying below 100 for a day.

 

I am currently experimenting with resistant starch (RS) to see if it will help. So far it seems like RS may indeed help, but I need more time to verify it. 

 

 

   Your goal is laudable, just keep in mind that Dr Bernstein does it with insulin. Its hard to pinpoint exactly where long term damage is occurring but I do know that trying to stay at numbers as low as yours while diabetic will require some serious intervention at some point. Its probably best to start trying insulin now if your wont settle for less numbers are below 5. Nothing else is going to keep you there long term.

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samuraiguy

Well then, I am being unreasonable! My goal is to have an A1c in the 4.2 to 4.6 range and a tight average around 83 mg/dl. This is what I consider normal blood glucose.

 

And this is exactly what Dr Bernstein recommends in order to avoid complications and to help reverse some complications. I also believe that complications clearly start in the pre-diabetic range and that any A1c over 5 can result in complications. When I was diagnosed with type II my A1c was only 6.5 (barley diabetic), yet I thought that I was dying because of the complications. Now after 6 months of an A1c of 4.9 and 4.7 most of these complications have gone or are going. 

 

I will admit that it is difficult for me to stay under 100, but I have manged to do so for days at a time (currently 6). Under 110 is easy and under 120 is easier still (I have been under 120 for months). A couple of months ago I had trouble even staying below 100 for a day.

 

I am currently experimenting with resistant starch (RS) to see if it will help. So far it seems like RS may indeed help, but I need more time to verify it. 

Good goal, but not necessary to avoid complications. NIH data shows the average mean A1C of Non-D's under 40 is 5, for those over 40 it's 5.6 (over 50% of those over 70 are in the prediabetic range). If those levels were so bad we'd see much more complications among non-D's and according to CDC statistics what they consider well controlled diabetics (A1C under 7) experience the worst complications less than 5 per 1000 patients.  Not saying those numbers should be the bench mark, but the stress for many to achieve very tight control would be worse than having slightly elevated blood glucose levels. Diabetes is the 7th overall underlying cause of death, stress is number 1.

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Ela

I'd go straight on insulin.  Usually it's only basal at least at first and maybe you wouldn't even need bolus - Hootie here is a good example.

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TX_Clint

I'm on 2000 met/day and did also use basal insulin like Hooterville. This worked ok but made my weight loss stall. I now take the met and 300mg of invokana with similar success so far. I would never attempt to achieve an A1c below 5.0. The risk of a deadly hypo bg event is too great.

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GAgirl

I would love to see a fbg at 100 or less, but I am a D, so it sure would be easier to do if I wasn't...also if I am under 120in the day after eating anything I am pleased. Would love i to be in the 90's all day- again, I am a D and my non-D friends are, but for me under 120 is great.

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William V

As an alternative: I found a change in strategy worked better and provided a few surprises. Rather than concentrating on making the low A1C readings, try to knock down the high BG readings. Monitor lots to look for any glycemic variability and concentrate on them. It moved my A1C down 0.3 so far. Excessive Glycemic Variability is actually far worse than continuous hyperglycemia. If you can afford it acquire a CGM for a few months as it is worth it.

Other than Met,  didn't notice any other medications listed. I found meds to be worse than the cure. e.g. Ive been taking Blood pressure med Atacand for several years. apparently it was the source of my excessive glycemic variability. It was only after 3 years weaning off of multiple drugs and feeling better (unknowingly some drugs to treat other drug side effects).  I found out BP med was a bad boy.

I have a CGM for over a year now. I view the CGM with may more respect than previously. It like looking at a full day security system movie as opposed to 4 - 10 timed snapshots during the same 24 hours. It was only after dialing in on many other BG related responses that the BP med issue became more visible and suspect. At present cq10, vit E may give the BP lowering effect. So for now, its just insulin.

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miketurco

A bg that is consistently over 140 is "supposedly" where organ damage and so forth begins. I read an in-depth article about that, with references to a number of studies. Wish I had the link on-hand now :/

 

I've been taking bg readings several times a day for the last few days. I'm between 110 and 120 in the morning, drift up to 136 to 155 by early afternoon, and then gradually come down to 100 to 110 throughout the evening. If I maintain this, my a1c will come down to a little under six.

 

An average bg of 140 equates to an a1c of 6.5. My last a1c, about six weeks ago, was 8.4 and my bg's have been going down since then, so I'm hopeful. I'm thinking my ultimate goal should be an a1c of less than 6. If I'm able to bring it down further, all the better.

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OldTech

I found meds to be worse than the cure. e.g. Ive been taking Blood pressure med Atacand for several years. apparently it was the source of my excessive glycemic variability. It was only after 3 years weaning off of multiple drugs and feeling better (unknowingly some drugs to treat other drug side effects).  I found out BP med was a bad boy.

I don't remember where I saw it, but a known side effect of beta blockers is to make BG control more difficult. Same with statins. One study showed that statins in a trial of people with diabetes raised BG an average of 10 mg/dl and their A1c an average of 0.6.

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Ela

A bg that is consistently over 140 is "supposedly" where organ damage and so forth begins. I read an in-depth article about that, with references to a number of studies. Wish I had the link on-hand now :/

 

I've been taking bg readings several times a day for the last few days. I'm between 110 and 120 in the morning, drift up to 136 to 155 by early afternoon, and then gradually come down to 100 to 110 throughout the evening. If I maintain this, my a1c will come down to a little under six.

 

An average bg of 140 equates to an a1c of 6.5. My last a1c, about six weeks ago, was 8.4 and my bg's have been going down since then, so I'm hopeful. I'm thinking my ultimate goal should be an a1c of less than 6. If I'm able to bring it down further, all the better.

 

This formula doesn't work exactly like this for everybody.  If I have your numbers (between 110 and 120 in the morning, drift up to 136 to 155 by early afternoon, and then gradually come down to 100 to 110 throughout the evening), I'll probably have A1C a bit ABOVE 6 or maybe even not "a little".  As by my home testing when my average was around 95 and practically always having FBG below 100 and rarely any numbers over 115 - I had A1C of 5.8, which is acceptable to me.   I seriously doubt that I can ever have A1C below 5 because my averages then should be ...what?  in 70th? 

 

Oh and the Old Tech poster, who had complications at 6.5 - well it's possible if you have a lot of highs and also balance them with lots of lows - A1C doesn't really give you the whole picture and all those highs ARE damaging.  And "barely diabetic" term is for the birds ... I mean for medical professionals. -_-   

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apollo322
A bg that is consistently over 140 is "supposedly" where organ damage and so forth begins. I read an in-depth article about that, with references to a number of studies. Wish I had the link on-hand now :/

 

I've been taking bg readings several times a day for the last few days. I'm between 110 and 120 in the morning, drift up to 136 to 155 by early afternoon, and then gradually come down to 100 to 110 throughout the evening. If I maintain this, my a1c will come down to a little under six.

 

An average bg of 140 equates to an a1c of 6.5. My last a1c, about six weeks ago, was 8.4 and my bg's have been going down since then, so I'm hopeful. I'm thinking my ultimate goal should be an a1c of less than 6. If I'm able to bring it down further, all the better.

 

Ok that's a lot more thorough picture, thanks for sharing. Based on those numbers yes you should add more met and probably try a few more things with diet and exercise. It's likely at those numbers right now you are higher than 6. But don't stress too much 6 weeks is still pretty new and you'll improve more over time. Losing weight and exercise can help a lot.

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OldTech

This formula doesn't work exactly like this for everybody.  If I have your numbers (between 110 and 120 in the morning, drift up to 136 to 155 by early afternoon, and then gradually come down to 100 to 110 throughout the evening), I'll probably have A1C a bit ABOVE 6 or maybe even not "a little".  As by my home testing when my average was around 95 and practically always having FBG below 100 and rarely any numbers over 115 - I had A1C of 5.8, which is acceptable to me.   I seriously doubt that I can ever have A1C below 5 because my averages then should be ...what?  in 70th? 

 

Oh and the Old Tech poster, who had complications at 6.5 - well it's possible if you have a lot of highs and also balance them with lots of lows - A1C doesn't really give you the whole picture and all those highs ARE damaging.  And "barely diabetic" term is for the birds ... I mean for medical professionals. -_-   

 

I agree that 'barely diabetic' is for the birds - you're still diabetic, but had my A1c been 6.4 rather than 6.5, I suspect my doctor would have said that I had pre-diabetes.

 

I really wish that I had been diagnosed earlier, but I am not sure that I would have responded to a diagnosis of pre-diabetes the same way especially if the doctor did not seem that concerned. That's why I am in favor of dropping the pre-diabetes term. Given what I know now I would recommend that any person with elevated BG take action to normalized their BG. And yes, I agree with you on the limited picture that A1c provides. Highs too are important and perhaps critically so in the transition from normal to diabetes.

 

I just found an in-vitro study that said that damage to human beta cells increase on a continuum from 100 mg/dl and up. It also appears that beta cells are also uniquely at risk for oxidation damage so it may be a combination.This is important. Up to now, I have just thought that there was just one level above which damage occurs. Based on these papers it is now clearer to me that BG damage occurs at different levels and duration depending upon the proteins and cells being impacted along with other factors such as oxidative stress. 

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OldTech

A1C doesn't really give you the whole picture  -_-   

 

A1c is not a 'real' statistical average it is only 'equivalent'. The process that generates the glycation of hemoglobin is a stochastic process involving the collision of glucose with hemoglobin and then a conditional attachment if it hits the right spot. There is also a time window in which attached glucose can become unattached. The actual measurement is just a percent of the hemoglobin A's that are glycated. It can be modeled as a stochastic function of concentration and exposure time. 

 

The reason that it is an average is related to the life of hemoglobin (about 90 days give or take). There is no need for lows to balance out the highs since the process is not a simple statistical normal distribution. It still though represents your overall BG for the period.

 

It is also an index of BG damage that is occurring elsewhere in the body since it is this same process that is occurring with all your other proteins and cells. 

 

I should also add that the function that maps A1c to average BG is derived from a statistical regression function of A1c and BG averages.

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Ela

I apologize to Mike - I quoted your post instead of Old Tech by mistake - please disregard it, it came out all wrong. 

 

I do get your concern and hope you'll find your answer and yes, as Apollo said earlier - maybe you should increase Met or revise your diet plan.  But also remember that diabetes is very unpredictable condition and personally I had periods when my BG were too high or too low without any known (to me) reason.  Stress, weather, sleep - everything could affect it.  So please try not to stress too much.

 

Good luck!

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miketurco

Follow-up. Ran tests and semi-random times throughout the week & did a graph, took that to the dr. My bg was all over the chart from about 100 to 160ish and the doctor said my sugar was "out of control." [n=37, avg=125, std=16.] He wanted to put me on a second medication. I suggested we max out the metformin for a month and see where that goes, and we agreed on that.

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