Monday, April 30, 2012

Metformin ( glucophage) effects Thyroid test

Diabetes ,  Metformin  effects Thyroid Test

Definitions :
Low thyroid  (hypothyroidism ) from various causes is diagnosed from symptoms and confirmed by laboratory test   The TSH ( Thyroid stimulating Hormone ) test is usually elevated
and the  T4 ( thyroid hormone ) level is decreased.

Subclinical hypothyroidism  ( someone with no symptoms are physical findings of hypothyroidism with an elevated TSH and low T4 )

Metformin effect
Metformin has an effect on TSH  and T4 levels in people with hypothyroidism.  Metformin decreases  TSH levels and may increase T4 levels making it more difficult to diagnosis and monitor treatment of hypothyroidism.

Complicates Thyroid replacement therapy
 Doctors follow TSH levels and adjust thyroid hormone replacement therapy to correct the TSH into the normal range. Metformin may complicate this process by making the TSH level appear lower than it is .
The mechanism of this effect is not known but one theory suggest that metformin may increase the absorption of thyroid hormone from the intestinal tract making a lower replacement dose adequate. This is an interesting unconfirmed idea .  Finding the correct replacement dose for someone on metformin will require some thought by your physician.

Complicates the diagnosis of subclinical hypothyroidism
The effects of Metformin on  lowering TSH  may  also interfere with the diagnosis of subclinical hypothyroidism

 People with normal thyroids do not seem to be effected by metformin. 

Have fun , be smart and understand your lab test.
David calder,MD

Metformin and Vitamin B12  tomorrow

Friday, April 27, 2012

Diabetes Cancer risk and " Drugs of Interest "

Diabetes medications that may be associated with cancer risk features 2 medications groups as "drugs of interest " , sulfonylureas and Insulin.

I have attached a few abstracts , copied from Medscape articles,  and high lighted statements of interest to our discussion today. Most of the articles I have reviewed seem to agree that there is some slight increase in cancer risk for people with Type 2 Diabetes.
 Metformin ( glucophage ) is generally associated with lower risk of cancer but attaching the higher risk of cancer label to other diabetes medications such as Insulin and Sulfonylureas remains in the category of  "drugs of interest ".  There seem to be a lot of " may be associated " in the discussions.
 Research into this area is  an ongoing process and we may have a definite answer in the future.

What should we do while waiting for a definite answer?  
Some of the newer medications , GLP-1 agonist and DPP-4 inhibitors ,  have given us tools that will allow full retirement of sulfonylurea medications and delay or even prevent the need for insulin in many people with Type 2 Diabetes.  This does not mean that we should delay moving to insulin quickly when other medications have failed to control blood glucose levels.  The benefits of insulin are much greater than the unproven risk of insulin.

 Please review my Feb 9 and 10 Blogs for more on GLP-1 agonist and DPP-4 inhibitors.

Have fun , be Smart , Ask your doctor specific questions and you will be amazed at the amount of wisdom and knowledge available to you today in your doctors office .

David Calder,MD

Mortality After Incident Cancer in People With and Without Type 2 Diabetes
Impact of metformin on survival
Author Affiliations
  • 1Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, U.K.
  • 2Global Epidemiology, Pharmatelligence, Cardiff, U.K.
  • 3Diabetes and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, U.K.
  • 4School of Public Health, University of Alberta, Edmonton, Alberta, Canada
OBJECTIVE Type 2 diabetes is associated with an increased risk of several types of cancer and with reduced survival after cancer diagnosis. We examined the hypotheses that survival after a diagnosis of solid-tumor cancer is reduced in those with diabetes when compared with those without diabetes, and that treatment with metformin influences survival after cancer diagnosis.
RESEARCH DESIGN AND METHODS Data were obtained from >350 U.K. primary care practices in a retrospective cohort study. All individuals with or without diabetes who developed a first tumor after January 1990 were identified and records were followed to December 2009. Diabetes was further stratified by treatment regimen. Cox proportional hazards models were used to compare all-cause mortality from all cancers and from specific cancers.
RESULTS Of 112,408 eligible individuals, 8,392 (7.5%) had type 2 diabetes. Cancer mortality was increased in those with diabetes, compared with those without (hazard ratio 1.09 [95% CI 1.06–1.13]). Mortality was increased in those with breast (1.32 [1.17–1.49]) and prostate cancer (1.19 [1.08–1.31]) but decreased in lung cancer (0.84 [0.77–0.92]). When analyzed by diabetes therapy, mortality was increased relative to nondiabetes in those on monotherapy with sulfonylureas (1.13 [1.05–1.21]) or insulin (1.13 [1.01–1.27]) but reduced in those on metformin monotherapy (0.85 [0.78–0.93]).
CONCLUSIONS This study confirmed that type 2 diabetes was associated with poorer prognosis after incident cancer, but that the association varied according to diabetes therapy and cancer site. Metformin was associated with survival benefit both in comparison with other treatments for diabetes and in comparison with a nondiabetic population.
Metformin Associated With Lower Cancer Risk
Allan S. Brett, MD
Posted: 03/26/2012; Journal Watch © 2012 Massachusetts Medical Society

  • Abstract and Introduction
  • Comment
Abstract and Introduction
Compared with sulfonylurea users, metformin users had a 10% lower incidence of cancer.
During the past decade, observational studies have suggested associations between cancer and type 2 diabetes (or insulin therapy). Although several plausible mechanisms exist (e.g., cancer cells express insulin receptors that when activated could promote cell proliferation in type 2 diabetic patients with hyperinsulinemia), the association remains controversial (CA Cancer J Clin 2010; 60:207). In some studies, metformin has been associated with decreased cancer risk.
In a population-based retrospective study, Dutch researchers recorded the incidence of cancer in 85,000 type 2 diabetic patients who initiated metformin or sulfonylurea monotherapy. During up to 10 years of follow-up, metformin users were less likely to receive cancer diagnoses than sulfonylurea users (hazard ratio, 0.9; 95% confidence interval, 0.88–0.91) after adjustment for age, sex, and several other variables. This 10% reduction was modest in relative terms but highly statistically significant. Metformin-associated lower risks were noted for cancers of the esophagus, stomach, colon, liver, pancreas, lung, breast, and prostate.

Section 1 of 2

Insulin Analogues and Cancer Risk: Cause for Concern or Cause Célèbre?

M. Pollak; D. Russell-Jones
Posted: 03/31/2010; Int J Clin Pract. 2010;65(5):628-636. © 2010 Blackwell Publishing

Abstract and Introduction


People with diabetes, particularly those with type 2 diabetes, may be at an increased risk of cancer. Furthermore, their cancer risk may be modified by treatment choices. In this respect, metformin may be protective, whereas insulin and insulin analogues can function as growth factors and therefore have theoretical potential to promote tumour proliferation. Analogues causing inappropriate prolonged stimulation of the insulin receptor, or excess stimulation of the IGF-1 receptor, are the most likely to show mitogenic properties in laboratory studies. Some recent epidemiological studies appear to be consistent with these experimental findings, suggesting that there could be different relative risks for cancer associated with different insulins, although these studies have attracted some methodological criticism. However, it is biologically plausible that hormonal factors that influence neoplasia could begin to manifest their effects in surprisingly short timescales (within 2 years) and hence these epidemiological studies justify further research. Even if future research were to document an increase in cancer risk among insulin users, this would be unlikely to significantly diminish the favourable benefit-risk ratio for patients requiring insulin therapy. There is a need for further population studies and for the development of new laboratory models that are more sophisticated than previous experimental methods employed to assess potential tumour growth-promoting properties of insulins.

Wednesday, April 25, 2012

Metformin reduces cancer risk

Question . What other diabetes medication also reduces our risk of cancer ?

Answer .   Metformin ( Glucophage )

A review in Medscape by Megan Brooks  reviewed a  study of women with ovarian cancer. 

The the study team reported in Obstetrics and Gynecology, five-year progression-free survival rates were 51% in diabetic patients who used metformin, 8% in diabetic patients who did not use metformin, and 23% in nondiabetics (p=0.03).
Overall survival at five years was 63% in metformin users, 23% in non-metformin users and 37% in the nondiabetic group (p=0.03).

Obstet Gynecol 2012;119:61-

From Reuters Health Information

There are numerous studies reporting the anti - cancer effects of metformin in various type of cancers. Medscape has over 200 articles reporting on metformin and cancer. Almost all of the articles are reporting on the benefits of metformin in reducing the risk associated with cancer and some animal studies discussing  the preventive aspects of metformin in cancer prevention. One article discussed the lack of effectiveness of metformin in reducing the mortality rate in women with advanced breast cancer . However they did not a trend in the reduction of distant metastasis in the women with diabetes taking metformin.
This is an exciting area of research that holds great promise in reducing all of the risk associated with cancer. I like the statement  made by Dr. Romero in the Medscape article.
Dr. Iris L. Romero and colleagues from the University of Chicago, Illinois say their observations add to a "growing body of evidence" from epidemiologic and preclinical studies indicating that metformin has anti tumor effects.

Have fun, be Smart and be your doctors best assistant in your own health care
David Calder, MD

Can you name 2 diabetes medications that may be associated with increased risk of cancer ?

Reporting an error. A few days ago I reported a price reduction in Diabetes Office Visit App. for iPhones and iPads.the change did not occur due to my error . I have corrected the problem. the new price is now .99 cents.

Tuesday, April 24, 2012

" daily aspirin reduces the long -term risk of cancer "

"Daily aspirin reduces the long-term risk of cancer" 
 This  quote was taken from an article article published in The Lancet , March 21 2012 and reviewed in Internal Medicine News  4/1/12

They study  data from 51  randomized studies comparing daily aspirin use  vs.  no aspirin and  adults who take a daily aspirin have a 15 % reduction in death from cancer compared to the non-aspirin  control group. Cancer death reduction was 37 % in the groups taking aspirin for over 5 years

If you look at the numbers :
       the overall 15 % reductions in deaths in the 51 studies reviewed ( 79,549 patients )
                   562  aspirin users compared to 664 non- aspirin users.

       In the 34 studies following patients for over 5 years  ( 69,000 patients )
                   92 deaths in the aspirin users compared to 145 deaths in the non -aspirin users

        In 6 studies of patients (35,500 patients ) taking low dose aspirin 72 mg/day for longer than 3 years
                   deaths in female aspirin users - 324 compared to 421 in non-aspirin users
                   deaths in  male aspirin users   - 192 compared to 245 in non - aspirin users
Daily aspirin has an absolute cancer risk reduction of 3.13 per 1000 patient per year.

This is more good news for us aspirin takers. 
 Question . What other diabetes medication also reduces our risk of cancer ?

Have fun , be smart and take your aspirin
David Calder,MD

Monday, April 23, 2012

Persistent cough . Is your blood medication the cause ?

Todays brief discussion is a continuation of our discussion of ACE inhibitors and ARBS . Please review the last few posts for more details.

 A persistent dry cough that develops while taking an ACE Inhibitor ( angiotensin converting enzyme  inhibitor) is a reason  to talk to your doctor. Dry cough is one of the common side effects of taking ACE inhibitors . Your doctor can change you to a different blood pressure medication and the cough should go away. If the cough continues after stopping the ACE inhibitor further evaluation may be needed.

Switching to a ARB ( angiotensin receptor blocker) is probable not a good idea.  The medications in each of these drug classes  effect the same systems in our body by different mechanism. Your doctor can chose from a variety of other blood pressure medications .

Have fun , Be smart and know the names and function of each of your medications.

David Calder ,MD

Saturday, April 21, 2012

Blood Pressure Medication alert for Diabetics

News alert from Medscape 4/20/2012

 The U.S. Food and Drug Administration ( FDA ) is warning of possible risk when using blood pressure medications containing aliskirin with ACE Inhibitors and ARBS  in patients with Diabetes  or kidney impairment. 

 Aliskiren Is often combined with other medications. Check your Blood Pressure medications and contact your doctor if aliskiren is present in any of your medications. I have listed some of the combinations below.

Aliskiren                                                                               ( Tekturna )
aliskiren, amlodipine ,hydrochlorothiazide combination ( Amternide )
aliskiren ,amlodipine                                                            (Tekamlo )
aliskiren ,valsartan                                                               ( Valturna)

Have fun ,  be Smart , be safe and know the name , contents and why you are taking any 

David Calder,MD

Angioedema with an ACE inhibitor. How about an ARB ?

More on the ins and outs of ACE inhibitors ( angiotensin converting enzyme inhibitor ) and
 ARBS ( angiotensin receptor blocker ) .

ACE inhibitor associated angioedema is not common and occurs in about 0.1 to 0.68  % of people taking ACE inhibitors

 Yesterdays question .
   Can a person who developed angioedema from a ACE Inhibitor take an ARB ?

 Answer . 
    My short answer is no. I would not personally prescribe an ARB for someone who had angioedema
    with an ACE inhibitor.  One study found that about half of patients with ARB associated angioedema
    had previously  developed angioedema  taking ACE Inhibitors.
   ( Angiotensin 2 receptor blocker  associated angioedema: on the heels of ACE inhibitor angioedem 
   Pharmacotherapy 2002; 25:1173-75   Abdi R,Dong VM ,Lee CJ, Ntosso KA)

  The etiology of ACE Inhibitor associated angioedema is thought to be associated with Bradykinin. Bradykinin is a potent blood vessel dilator. ACE Inhibitors slow down the clearance of bradykinin from our body. This is generally a good thing and helps lower blood pressure and a bad thing when it causes angioedema.
Todays question :

   Can a person with a history of angioedema from any cause known or unknown take a ACE
   Inhibitor or ARB ?

 Answer : 
     My short answer is no. There are plenty of other Blood Pressure medications with lower risk.

Tomorrow - Persistent cough  ? Could it be your ACE Inhibitor ?

News alert from Medscape 4/20/2012

 The U.S. Food and Drug Administration ( FDA ) is warning of possible risk when using blood pressure medications containing aliskirin with ACE Inhibitors and ARBS  in patients with Diabetes  or kidney impairment.  Aliskiren Is often combined with other medications. check your Blood Pressure medication and contact your doctor if aliskiren is present in any of your medications. I have listed some of the combinations below.

Aliskiren                                                                               ( Tekturna )
aliskiren, amlodipine ,hydrochlorothiazide combination ( Amternide )
aliskiren ,amlodipine                                                            (Tekamlo )
aliskiren ,valsartan                                                               ( Valturna)

Have fun ,  be Smart , be safe and know the name , contents and why you are taking any 

David calder,MD

Friday, April 20, 2012

Your Blood Pressure - Angioedema - ACES and ARBS

 What are ACE inhibitors and ARBS . These medications work in different ways to reduce  the effect of angiotension 2  on our blood pressure.

The enzymes and the receptor blockers

ACE ( angiotension converting enzyme ) - converts Angiotensin 1 to Angiotension 2

Angiotensin- 2 -   a very potent constrictor of small arteries increasing blood pressure

ACE inhibitors - partially blocks angiotension converting enzyme and allows dilation of small arteries
                             lowering blood pressure . (see yesterdays blog for a list of ACE Inhibitors)

 Angiotensin -2 Receptor   - angiotensin 2 has to connect into a receptor on our arteries 
                                               to effectively raise blood pressure

ARBS ( angiotensin receptor blockers ) -   lowers blood pressure by interfering with the ability of 
                                                                    angiotensin 2 to connect to small arteries .

List of Angiotensin receptor blockers
losartan       ( Cozaar ) 
valasartan   ( Diovan)
irbesartan    ( Avapro )
candesartan ( Atacand )
azilsartan      ( Edarbi )
eprostartan   ( Teveten )
olmesartan    ( Benicar )
telmisartan    ( Micardis )

We started this conversation discussing 2 cases of an unusual complication of ACE inhibitors , Angioedema. 
Can a person who has had angioedema with ACE inhibitors take a ARB ?

The answer tomorrow. 

Have fun, be Smart , be Safe - understand  more about your blood pressure pills
David Calder, MD


Thursday, April 19, 2012

Diabetes Office Visit App. on sale .99 cents

Diabetes Office Visit- Helps you prevent Heart Disease

          Diabetes Office Visit  iPhone and iPad  App. is on sale   $0.99  for a limited time.  
                     The sale is to celebrate a new update  that  will be available soon .
Look for improvements in the the Risk Management section and  Lab. test reports  can be followed in either mg/dl or mm/l.
click on the Training Video  link above for better understanding of goal setting , cardiovascular risk management and data that is always at your finger tips.

Have Fun , Be Smart and use the tools in Diabetes Office Visit  to prevent heart disease
David Calder,MD

               Diabetes office visit                                                    
                                                             " fixing the 9 "                                    
*CREATED BY David Calder MD to provide an always at your finger tips comprehensive diabetes management tool , that will simplify your diabetes care and help you preserve your good health. 
Diabetes control is more than just controlling blood glucose levels.
Heart disease and stroke risk is increased for people with diabetes and is the number one cause of disability and death for people with and without diabetes. 
This does not have to happen, It is your choice.     Chose wisely.

Over 36 million people in the United States with diabetes have 9 primary risk factors   to manage. ( just numbers ) 
One study found that only 7% of people with diabetes achieve target goals for A1c, Cholesterol and blood pressure. (JAMA 2004; 291:335-342, a recent update in 2010 showed an improvement to 11%) 
Diabetes Office Visit can significantly improve those numbers by simplifying risk management to managing 9 numbers. 

How do we do it? 

Simple and Specific Goals Empower each of us to do better

Start Simple, Set Goals 
Initially, you don’t have to know what the numbers mean to affect them.You just need to learn the targets and what levers to pull to move your numbers toward the target. The first lever to pull is learning how to discuss the Lab values with your doctor. The Diabetes Office visit suite empowers you to have that conversation.
Remember : “ You fail to achieve 100% of the goals you don’t set “ 

Be Specific
Diabetes Office Visit provides the goals and a patient-focused template for a conversation with your doctor about your goals. The point is to focus each conversation on the specific goals where you are not hitting the target. 
Repeat, Repeat, Repeat. 
Over time, repeated conversations about your lab values create opportunities for you to learn how to better manage this disease. 
Our goal is to empower you to gain understanding of this disease over time and actively partner with your health care provider to manage it. 
Fixing the Nine, Why it Works 
Correcting just one risk factor is already proven effective !  
The Heart Protection Study,focused on LDL cholesterol over a 5 year period and prevented a major vascular event in 70 to 100 people per 1000. A key finding was that regardless of whether you do or don’t have diabetes, and whether you do or don’t have heart disease, you benefit from treating one risk factor for heart disease. 
Correcting a few more cardiovascular risk factors saves lives... 
Blood pressure control reduces the risk of heat disease and stroke among people with diabetes by 33 to 50 percent. 
Diabetes office visit provides you with the tools to make this happen 
Visit my web site daily, for more references and more studies and discussions on how you can better manage 9 known risk factors and preserve your good health. “Fixing the nine” will work for you. 
email me - with comments , questions , ideas and complaints
Regular mail- Diabetes Office visit PO Box 1170 Creswell, Oregon 
Diabetes Office is available in paperback , ebook and iphone ipad App versions and all are supported by my web site, .I will soon have an App version for MAC's and PC's

Check out the DiabetesOffice Visit training video tab on the home page

If you are unhappy with this app Ebook or paper back book for any reason , I will return your money. 
Thank you David Calder,MD

Blood pressure pills and a numb tongue ( left side only)

The two patients presented yesterday have the same diagnosis , angioedema. 
The cause of the angioedema was lisinopril.


Angioedema is a transient swelling of subcutaneous tissue with multiple triggers that can be;

   Allergies -  such as food allergies ( nuts , shell fish , eggs ) , medications (penicillin  sulfa and others )
                    insect bites  and latex are common
   Hereditary angioedema

Non - Allergic Drug Reaction  - ACE Inhibitors

  I would like to focus our attention on the Non- Allergic drug reactions seen with medications called
  ACE Inhibitors . Lisinopril is a ACE inhibitor and was taken by both of the patients  discussed

   ACE inhibitors are excellent safe medications used by millions of people with diabetes to treat high
   blood pressure and to help protect  their kidneys from the damage caused by diabetes.

The Symptoms , are unusual atypical mimics

The symptoms of ACE Inhibitor induced angioedema are atypical and mimic other more common problems such insect bites , hives ,  heart and gall bladder disease.

  There are a few symptoms are more specific to angioedema.
     #1 the symptoms usually occur on one side of our body and resolve in hours to days with no residual
             Our patient number 2 had recurrent swelling and itching of either the top of his right  or left foot 
             and  numbness swelling and tingling of the left side of his tongue

     #2  atypical chest or upper abdominal pain with abnormal liver test that return to normal  within a few
     #3   Angioedema can occur with the first dose or after years of being on the medication.
               A physician friend of mine had one patient develop severe angiedema of her throat after taking
               her first pill . Our patients # 1 and 2 developed symptoms after years of taking lisinopril.

     #4   There may be a family history of allergies to medications. 
                Our patients #1 is allergic to Dilantin,and has a son and daughter allergic to penicillin.
                Our patient #2 is allergic to penicillin , has hay fever and mild asthma and has a son allergic to
                latex and penicillinA.

ACE Inhibitors are common very useful medications
 Lisinopril ( prinivil , Zesteril )                                          
  Captopril  (capiton )
  Ramipril  (Altase )
  Enalapril  ( Vasotec enalaprilat )
  Quinipril   ( Accupril  )  
  Benazepril  ( Lotensin )
  cilazapril     (Inhibace )
  fosinopril    ( monopril )
 moexipril     (Univasc )
 perindopril   ( Aceon , Coversyl )
 Trandolapril ( Mavik )

  It is hard to remember all of these different brands . Did you notice the generic names all end in "pril "
Have fun , be smart and understand the medication the medicines you are taking
David Calder , MD

Tomorrow!  What about them ARBS and are they related to ACE. 


Wednesday, April 18, 2012

Different symptoms with the same diagnosis. This could happen to you?

I will present 2 cases of patients with pre-diabetes , mild hypertension , dyslipidemia who have very different symptoms of the same medical problem.

Case #1 72 y/o male with a  Fasting blood glucose of 116 mg/dl, A1c of 6.1,
                                              Blood Pressure 126/78
                                              Cholesterol 116
                                              LDL             57
                                              triglyceride 114
                                              HDL            36

Medications  zocor  ( simvastatin )           20 mg/day for  2 years
                      lisinopril                              20 mg/day  for 3 years
                      metformin                          500 mg twice daily
                      aspirin                                  85mg/day
                      omega -3 FA                     960 mg twice daily

Symptoms .  recurrent episodes , separated by weeks or months , of a stinging sensation followed by itching and swelling of the top of his right or left foot . The swelling and itching would subside over the next 4 to 5 days and he would be asymptomatic until the next episode. He attributed the symptoms to  insect bites.
One afternoon while watching TV he developed a numb tingling swelling sensation in the left half of his tongue that lasted about 1 hour. The tongue symptoms prompted a doctor visit .

A diagnosis was made , treatment was started with complete resolution of all symptoms.

What is your diagnosis ?

Case #2  71 y/o female with a : Fasting glucose of  112
                                                  Blood Pressure       132/86
                                                  Cholesterol             168 mg/dl
                                                  LDL                         66 mg/dl
                                                  HDL                         52 mg/dl
                                                  Triglycerides           249 mg/dl
  Medications        Zocor  (simvastatin )                     40 mg/day for years
                              Omega -3 -Fatty Acid               4000 mg/day for years
                               Lisinopril                                      40 mg/day for years
                               coumadin                                        5 mg/day for 3 years


     The sudden onset of  severe chest pain , nausea , sweating and difficulty breathing. The symptoms subsided in the emergency room. Her physical exam , EKG, chest x ray and test for heart damage was normal. They did find 3 abnormal liver test.  She had similar symptoms about 15 years ago which resulted in a diagnosis of gall bladder disease and surgery.She had repeat liver test the next week that were normal.She saw a cardiologist who could not find any evidence of heart disease. She continued to have the same recurrent symptoms , multiple Emergency room visits. Abnormal liver test that quickly returned to normal were present with each episode of pain . She was referred to a gastroenterologist to for further evaluation and to rule out a retained gall stone. After the visit and plans for further invasive studies  were discussed . A doctor friend suggested a unusual  possible diagnosis.  Treatment was initiated  with complete resolution of her symptoms.

What is your diagnosis ? 
Are these 2 cases the result of the same problem?
The clue to the diagnosis of both cases is discussed above.

Have Fun  Be Smart and make a diagnosis and don't overlook these symptoms.
This could happen to you

The answer and discussion tomorrow.

David Calder, MD


Wednesday, April 11, 2012

Sulfonylureas are still controversial

 Medscape published another review written by Mathew  L. Mintz, MD Matthew L. Mintz, MD 
.Sulfonylureas in Diabetes: Why So Controversial?

This is a topic worth continued attention. He reviews the recent guide lines of the American 
college of Physicians. This group recommended metformin as the first medication choice when diet and exercise fail and suggested a more individualized approach when metformin alone is not enough .
Medication  effectiveness is about the same with most of the other medications,however  the other issues such as safety, weight gain and preservation of Beta cell is different.

         Safety - hypoglycemia with sulfonylureas is  6 times more common  than with drugs 
                       such as pioglitazone ( ACTOS }. Hypoglycemia is also a problem with insulin.

        Weight gain - sulfonylureas , pioglitazone  ( edema ) , insulin

        Preserve Beta cell function - "Sulfonylureas seem to "burn out" the Beta cells and fail ".

                                                            pioglitazone  and probable DPP-4 inhibitors and GLP-1 
                                                            agonist preserve Beta cell function

        Least expensive -  sulfonylureas
        Known risk-          sulfonylureas
The last 2 items listed , known risk and cost , have a significant  effect on our choices of medications. The newer medication may have risk that have not yet surfaced. 

The glitazones , Actos ( piogliatzone) and Avandia ( rosiglitazone  ) have their issues with edema , questionable heart problems with Avandia  ,and bladder tumors in mice with piogliazone . These  problems have limited their use.  

The unknowns of the newer medications such as DPP-4 inhibitors and GLP-1 agonist are still out there. There is a hint of increased increased risk of pancreatitis.

The increased cost of newer medications is always a problem. The article suggest there may be some relief from the cost.
"In the United States, however, drug manufacturers offer discount cards for most branded combination pills, which reduces a patient's out-of-pocket costs to almost the same as that of adding a sulfonylurea to metformin. For example, monthly supplies of 2 dipeptidyl peptidase-4 (DPP-4)/metformin combinations -- Kombiglyze™ XR and Janumet® XR) are available for $10 or less with the manufacturer's discount card."

Please review my previous blogs for more details .


Diabetes medication , the first choice is easy, the second choice is not as easy


New Diabetes Meds= High Cost ! Hypoglycemia to the Rescue ?


Glucophage "failed " Now what should I do ?

Have fun , Be Smart and chose your diabetes medications carefully
David Calder,MD