Sunday, December 23, 2012

Metformin ( glucophage )reduces Cardiovascular risk

The December 10,2012 issue of Diabetes Care has an article of interest related to yesterdays discussion of glipizide and metformin.

Effects of Metformin Versus Glipizide on Cardiovascular Outcomes in Patients With Type 2 Diabetes and Coronary Artery Disease.                                                                     

They studied 304 patients with Type 2 Diabetes with a history of coronary artery disease.

Patients were randomly assigned to either metformin 1.5 gms/day or glipizide 30 mg/day.

The medium followup  was 5 years and both groups achieved similar A1c results
 ( 7.1 in the glipizide group and 7.0 in the meformin group )

  Treatment with metformin for 3 years substantially reduced major cardiovascular events during the 5 year followup.

Have Fun, Be Smart and read pages 44 and 45 in Diabetes Office Visit and talk to your doctor about metformin

David Calder, MD

Saturday, December 22, 2012

Why are my glucose test high ? Continued .

Today is a continuation  of the post from 12/16/12

                               Why are my blood test high on glipizide ?


  This person had stopped ACTOS, because of concerns about risk, started glipizide and then noticed an increase in blood glucose levels. There was no mention of glucophage( metformin ) being used .
I had not yet received a reply to my questions about medication history , especially regarding glucophage.

My suggestions for further discussions with her physician
 Unless there is a contraindication ,Glucophage (metformin) is generally accepted as the drug of first choice for patients with type 2 diabetes.
My suggestion is that this person talk with his / her physician about the  possible use of metformin with glipizide. This combination may be effective in correcting blood sugars but the glipizide  does increase hypoglycemia risk. The risk is the highest in late afternoon and the early morning hours , 2 to 3 AM.

Glucophage combinations with almost no risk of hypoglycemia
There are other combinations with metformin that may be more effective without the risk of hypoglycemia.
    Metformin plus a DPP-4 inhibitor ( Januvia , Onglyza or Tradjenta )
    Metformin plus a GLP agonist such as Byetta, victroza or once weekly Bydureon

I have attached previous post that may improve your understanding of glucophage, DPP-4 inhibitors, GLP-1 agonist , sulfonylureas and lizard spit.

Metformin( glucophage) - better understanding of a...

Monday, December 17, 2012

Diabetes Office Visit App update has new features

Thanks to the talent and skills of Rudy and Carolina Amarayo owners of OribitusRoboticsLLC the new update is complete and as usual , includes Rudy's extra touches making the App much better than I expected.

Rudy Aramayo | Founding Developer | OrbitusRobotics LLC
Direct979.209.9129 |
The new update includes :
  Treatment Goals
   #1 laboratory test results can be viewed as mg/dl ( most common in the United States ) 
       or in mm/l (more common in other countries
  #2 You can now compare your latest laboratory test results with your treatment goals by just touching
       the DATA button at the bottom of the page

 Risk Management Section
     This section allows you to enter your most recent laboratory test or exams and the data will be
    This allows you to keep track of your own results and improvement.
    There is also a Custom User Data section at the bottom of the page. This area allows you to add
     test  and exams of interest to you and your physician.

 There is two little problem that will corrected with the next update
   #1 You will need to erase the name and data title  before adding your test otherwise it
        will show up with data you are entering.
   #2  Goal setting for glucose results is usually a range ie. 90 to 130.  The app at present does not allow
          for ranges
User tip ( comparing your test results with the recommend target goals)
The goal setting and risk management sections are probable the most important parts of Diabetes office visit. By just touching the Goals icon( the little light house in lower left hand side of the screen )  when you are in risk management allows you to compare your test results with your recommended goals .

  Always at your finger tips  
   Have fun ,Be Smart always get a copy of your  laboratory test result  and add along with important
   exam results to your Diabetes Office Visit App.

David Calder, MD

Sunday, December 16, 2012

Why are my blood test high on glipizide ?

  1. I am interrupting the hypoglycemia discussion  to start a discussion about a  current  problem someone is having today. 
    I will continue the hypoglycemia discussion later.
    The short answer to the previous post question , Is severe hypoglycemia associated with increased mortality, is yes. The discussion and longer answer will be later.
    Also ,  The Diabetes Office visit App update is done and the risk management section is much improved . I will review this in detail later. To celebrate , the price has been reduced to .99 cents starting today.
    Todays post

    I have the same question as a previous inquirer. I started glipizide at 10 miligrams in divided doses after switching from Actos. I had to drop Actos because of some other undesirable side effects, not to mention all of the ads about bladder cancer. (However, during Actos I had blood sugars about 140-150 and A1C of 6.6), but one month after starting Glipizide, A1C went to a 7.3 with blood sugars right under 200, then my doctor upped the glipizide to 15 mg. with 10 mg. in the morning and 5 at night. Well then my blood sugar started going way up in the 200s, about 270 though eating the same diet as with the Actos. I am not mistaken, my blood DID increase on this medicine. I am a careful food eater, and test regularly, so could you please explain why????
  2. Great question.
    I will respond with a few questions and ask you to read some of my previous related post to help you better understand the medications available to help you do a better job managing your diabetes.
    Stopping ACTOS was a good decision.

    Is there some reason you chose glipizide as your choice to replace ACTOS ?

    Is there some reason that you cannot take metformin ( glucophage) ? Kidney disease ? intolerance to glucophage ?

    Is the 140 to 150 fasting blood sugars , before or after meal? Your Fasting blood sugar is one of the best indicator of insulin deficiency.

    Your blood sugars increased because of insulin deficiency . The primary problem of type 2 diabetes is the progressive loss of adequate insulin production. 
    The good news is ; 
    The are number of medications available to help you manage this problem. 
    I would like to continue this discussion after you read some of my previous post on this subject. I think together and we can improve your understanding of the options available and enhance the discussion of your treatment options with your physician.

Diabetes medication , the first choice is easy, th...

Metformin( glucophage) - better understanding of a...

This is a good combination pill -sitagliptin and ...

Glucophage "failed " Now what should I do ?

Glucagon effects your life every day

New Diabetes Meds= High Cost ! Hypoglycemia to the...

Good news. A once a week diabetes injectio

Bydureon is my first choice for a second medicatio...

I am looking forward to your response

Have fun, Be Smart and be aware of your treatment options
David Calder, MD

Wednesday, December 12, 2012

Does age effect a person awareness of hypoglycemia?


Take home message from the November 18 post 
    Epinephrine produces the early warning symptoms of a dropping blood sugar. The loss of the
    epinephrine response to a falling glucose results in " hypoglycemia unawareness " and the 
    progression to the more severe stages of hypoglycemia. I have attached the Nov.18 post below

   for your review of some of the physiology associated with hypoglycemia.

      Does age effect a persons awareness of low blood sugars ?

   The answer is probably yes according to a few articles in Diabetes care*. 
     Zammitt NN, Frier BM . Diabetes Care. 2005; 28(12) 2948-2961
      Matyka NN et al. Diabetes care. 1997;20(2) : 135-141
    The studies were done  comparing non diabetic men age  23 +-3 years to "more mature " men  65 
     +- 3  years old.
      They compared the time lapse from the onset of  early warning symptoms of  sweating ,shaking  ,anxiety  to the development of of neurological symptoms , confusion, dizzy, headache  weakness , irritability ,belligerent behavior and sleepiness.

                                     Early warning symptoms begin                   Neurological symptoms begin
                                      with Glucose levels                                       with glucose levels

  men 23 +- 3 years          65mg/dl ( 3.6 mm/l )                                       47 mg/dl ( 2.6mm/l )

  men  65 +-3 years           55 mg/dl ( 3.1 mm/l )                                     50 mg/dl ( 2.8 mm/l )    

It appears that the reaction time available between the onset of early warning symptoms ( Glucose 55mg/dl ) and the onset of neurologic symptoms ( 50 mg/dl ) decreases with advancing age in non diabetic men. ( it is probable the same for men and women with diabetes)
This loss of early warning symptoms can also occur within a few years of developing insulin dependent diabetes regardless of age.
Take home message
 Older people have , in addition to the decreased awareness of developing hypoglycemia ,  less time to take corrective  measures to treat developing hypoglycemia.  
This development  can have a major impact on a older persons independence , leading to  a change in their living situation and  loss of their drivers license. 

Short Term vs Long Term Risk
  The risk associated with hypoglycemia is immediate , Short Term . Avoiding the risk of hypoglycemia is a major factor in setting A1c target goals .

It is good to remember that one benefit of getting older is that long term gets shorter , allowing the slight risk associated with of an A1c between  7 to 8 range to become less important .   

Have Fun , Be Smart  and remember getting a little older does have a few benefits
David Calder , MD                   

Question , Is there an increase in mortality associated with severe hypoglycemia ? 
The answer tomorrow. 

My tomorrows have become a little spread out  over the  last two months because of time constraints of work , buying  and remodeling a new home while preparing our current home for sale .

 For your review
NOV. 21 post
 Does lowering A1c result in increased hypoglycemi...


November 18 ,2012

                    A few definitions and a little physiology about low blood sugars

Diabetes and the Devil of low blood sugars

I have always felt that people with diabetes have to work a little harder each day to preserve their good health while being forced to walk a narrow path between 2 devils .  The Devils of high and the Devils of low blood sugars .The devil of high high glucose comes with known long term risk and the devil of low glucose levels , on the other side of the path , comes with immediate often severe consequences. This is the beginning of a 4 part discussion of hypoglycemia. Today, I will lay the ground work with a few definitions and  a little physiology .

 The American Diabetes Association's discussion of hypoglycemia. Position statement 2012
"Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and type 2 diabetes.

Mild hypoglycemia - plasma glucose below 70 mg/dl

Severe hypoglycemia -
  ( where the individual requires the assistance of another person and cannot be treated with oral
    carbohydrate due to confusion or unconsciousness) should be treated using emergency glucagon kits)
Hypoglycemia unawareness
  (In type 1 diabetes and severely insulin deficient type 2 )
  These people of lost their awareness of the early warning signals of hypoglycemia

Joslin's Diabetes Mellitus thirteenth edition has a good chart on page 495 . It matches our bodies response and symptoms to decreasing blood glucose levels. I have adjusted the medical terminology slightly to meet the needs of this discussion.

 Counter regulatory hormones .
 These are hormones our body releases in an attempt to correct a falling  blood glucose  level.  Some of these hormones produce the early warning symptoms that we associate with hypoglycemia.

    Glucose level               Increase counter regulatory hormone         Effects and symptoms 
      < 70 mg/dl                         increase glucagon                                   increase in glucose from liver
      < 70  mg/d/                        increase Epinephrine                               increase glucose, feeling of 
                                                                                                                anxiety, sweating , shaking,
     < 65 mg/dl                          increase cortisol and growth hormone     increase glucose levels

     < 60 mg/dl                                                                                           neurological symptoms
                                                                                                                     confusion, dizzy
                                                                                                                     irritability , sleepy
                                                                                                                     belligerent behavior
      < 40                                                                                                        lethargy , Coma

Take home message
    Epinephrine produces the early warning symptoms of a dropping blood sugar. The loss of the
    epinephrine response to a falling glucose results in " hypoglycemia unawareness " and the 
    progression to the more severe stages of hypoglycemia.

Have Fun , Be Smart and avoid hypoglycemia
David Calder,MD

     Does lowering A1c result in increased risk of hypoglycemia in type 1 and type 2 diabetes ?
     Does age effect a persons awareness of hypoglycemia