Type 1.5 Diabetes And Metformin

What Next When Metformin Isn't Enough For Type 2 Diabetes?

› Turn first to metformin for pharmacologic treatment of type 2 diabetes. A › Add a second oral agent (such as a sulfonylurea, thiazolidinedione, sodium-glucose cotransporter-2 inhibitor, or dipeptidyl peptidase 4 inhibitor), a glucagon-like peptide-1 (GLP-1) receptor agonist, or basal insulin if metformin at a maximum tolerated dose does not achieve the HbA1c target over 3 months. A › Progress to bolus mealtime insulin or a GLP-1 agonist to cover postprandial glycemic excursions if HbA1c remains above goal despite an adequate trial of basal insulin. A Strength of recommendation (SOR) A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series The "Standards of Medical Care in Diabetes" guidelines published in 2015 by the American Diabetes Association (ADA) state that metformin is the preferred initial pharmacotherapy for managing type 2 diabetes.1 Metformin, a biguanide, enhances insulin sensitivity in muscle and fat tissue and inhibits hepatic glucose production. Advantages of metformin include the longstanding research supporting its efficacy and safety, an expected decrease in the glycated hemoglobin (HbA1c) level of 1% to 1.5%, low cost, minimal hypoglycemic risk, and potential reductions in cardiovascular (CV) events due to decreased low-density lipoprotein (LDL) cholesterol.1,2 To minimize adverse gastrointestinal effects, start metformin at 500 mg once or twice a day and titrate upward every one to 2 weeks to the target dose.3 To help guide dosing decisions, use the estimated glomerular filtration rate (eGFR) instead of the serum creatinine (SCr) level, because the SCr can translate into a variable range of eGFRs (TABLE 1).4,5 What if metfo Continue reading >>

Metformin For Type 1.5?

Diabetes Forum The Global Diabetes Community Find support, ask questions and share your experiences. Join the community I have LADA/1.5 and have been advised not to worry unless my bg's hit 13. They have been creeping up for a while and 7-9's after fasting is now not uncommon for me. Should I enquire with my DSN about Metformin if they are not willing to use insulin until I'm in the 13's? I know it is used primarily for t2's but have read that it has been used successfully for short periods with t1.5's. I am LADA on insulin and also on 2g of metformin, so can't see why not. I'm LADA type 1.5 and take 500mg Metformin MR plus insulin after evening meal What were your levels like when you started medication? Just wondering what's normal for the start of meds. Hey I take 2x 500mg Metformin per day, it's definitely worth it because the way it works is that it makes your body more receptive to the insulin you DO produce so while ur still producing some it will help. I'm surprised they haven't suggested it really? Alot of people say it only brings you down by 1-2mmol but that's not true because when I went through a switch from standard release to slow release Metformin my BS shot up by at least 4mmol in the overlap time whilst the new tablets started working. I think us 1.5s are a complete mystery lol Diagnosed with GD in 2010, Completely disappeared postpartum. Re-diagnosed December 2012 with type 1.5 diabetes, age 26, BMI 23 currently controlled by only Metformin, 500mg twice a day. If it brings you down by 4mmol then they probably won't prescribe it then as I'm only at 7-9 after fasting. My post meals are usually in range, it's just my fasting that I'm struggling with. I was diagnosed withDiabetes in Dec, Type unknown and put on Gliclazide then Metformin after the Gliclaz Continue reading >>

Case Studies | Beta Cells In Diabetes

Diagnosing LADA in Adults with "Brittle Diabetes" A 52-year-old male presents with brittle diabetes. He was diagnosed three years ago with type 2 diabetes (T2DM). His A1C was 10.6% at that time. He was started on metformin and titrated up to 500 mg at breakfast and lunch and 1,000 mg at dinner. The patient is 60 and 161 lbs. with a BMI 21.8; BP of 128/82, and pulse of 69. Blood tests show his current A1C as 8.7%, triglycerides as 131 mg/dl, HDL as 53 mg/dl, and LDL as 97 mg/dl. Is T2DM the correct diagnosis for this patient?A 52-year-old male presents with brittle diabetes . He was diagnosed three years ago with type 2 diabetes (T2DM). At the time of diagnosis, he had problems with fatigue, vision changes, the polys and a recent 15 lb. weight loss. His A1C was 10.6% at that time. He was started on metformin and titrated up to 500 mg at breakfast and lunch and 1,000 mg at dinner. He is still taking metformin on that schedule, plus acetylsalicylic acid (ASA) to prevent cardiovascular disease. The patient reports that he monitors his FSG, and most mornings his glucose is 100-130 mg/dl, but he spikes to >200 mg/dl with all meals, especially if he eats things with carbs. He is frustrated that his glucose is not better all of the time despite his efforts. He says he is eating a restrictive diet and controlling portion size. He has a history of asthma for which he still uses a beta agonist inhaler as needed, and an inguinal hernia. He does not use tobacco, alcohol, or recreational drugs. He has never had pancreatitis. He does not have a family history of diabetes. However, heart disease is present in both parents, and one sibling has autoimmune thyroid problems. Physical exam is otherwise normal. The patient is 60 and 161 lbs. with a BMI 21.8; BP of 128/82, and pulse of 69. B Continue reading >>

Lada And Gad: Diagnosing Type 1.5 Diabetes

Researchers in Germany have further endorsed the effectiveness of a blood test that helps determine whether some adult diabetics diagnosed as type 2 diabetes are actually in the early stages of having type 1 diabetes. Latent Autoimmune Diabetes of Adults (LADA) like type 1 diabetes, is an autoimmune response that that destroys insulin-producing beta cells in the pancreas. It is often misdiagnosed as type 2 diabetes because it looks and acts a lot like type 2– arising usually in adulthood and progressing slowly– but, unlike type 2 diabetes, LADA results from the autoimmune destruction of insulin-producing beta cells. A test for glutamic acid decarboxylase, or GAD, antibodies, has long been used as a method of differentiating between LADA (which is sometimes referred to at type 1.5 diabetes) and type 2 diabetes in people over age 30. With LADA as well as type 1 diabetes, the body’s immune system begins to attack its own beta cells. When the immune system attacks pathogens, one weapon in its arsenal is the creation of antibodies that bind to the foreign objects and mark them as invaders. In the case of autoimmune diabetes, the body begins to create antibodies against parts of proteins that are not foreign, but rather are associated with its own beta cells. GAD is one of the earliest proteins to be targeted by antibodies, and so by testing for the presence of GAD antibodies, doctors can determine whether there is an autoimmune reaction to beta cells taking place. “At diagnosis, people with LADA usually do not require insulin right away because they are still producing some insulin,” according to Christy L. Parkin, MSN, RN, CDE, Associate Editor of Diabetes Forecast. “Because of their older age, they are often misdiagnosed as type 2 and started on oral medication Continue reading >>

Lada: A Little Known Type Of Diabetes

Dr. Nguyen is a clinical pharmacy writer based in San Jose, California. Dr. Muzyk is a freelance clinical pharmacy writer based in Tampa, Florida. In recent years, researchers have discovered another form of diabetes, referred to as latent autoimmune diabetes in adults (LADA). Some other names for LADA include diabetes type 1.5, slow-progressing type 1 diabetes, and late-onset autoimmune diabetes.1-4 Although different names have caused confusion, they all refer to a subset of patients with type 2 diabetes who have antibodies and genetic factors commonly found in those with type 1 diabetes. LADA is often misdiagnosed as type 2 diabetes because its onset occurs during adulthood.3,4 In addition, patients may still have some healthy b-cell function and thus do not require insulin therapy initially. Patients with LADA can adequately control their blood glucose by making lifestyle changes and taking oral hypoglycemic agents at early stages. Unlike patients with type 2 diabetes who may never need insulin, however, those with LADA will continue to experience a decline in b-cell function and will eventually progress toward insulin dependency. One factor that is central to the pathophysiology of diabetes is insulin resistance. Many studies agree that insulin resistance in LADA is higher than in recent-onset type 1 diabetes and is similar to long-term type 1 diabetes.1,5-7 Some studies showed that patients with LADA have less insulin resistance, compared with those with type 2 diabetes; however, others did not find a difference between the 2 groups.1,5-7 Besides having a similar clinical presentation as that of type 2 diabetes, LADA carries many immunologic and genetic features of type 1 diabetes. In classic type 1 diabetes, the 4 common islet autoantibodies responsible for attac Continue reading >>

Ketoacidosis In A Patient With Type 2 Diabetes – Flatbush Diabetes

There is increasing recognition of a group of patients with type 2 diabetes who can present with ketoacidosis. Most reports have been of patients of African descent; however, the condition has been reported in other groups. This is a case of a Caucasian patient who has had three presentations with ketoacidosis and whose diabetes is not usually insulin-dependent. A patient, aged 48 years, presented with diabetic ketoacidosis (DKA) in a semi-comatose condition. She had a 3-day history of vomiting and loss of appetite. In the previous weeks she had undergone radiotherapy for metastatic squamous cell carcinoma (skin primary). The patient had two similar episodes of DKA, one 20 months and another 3 months earlier. Two of the patient’s brothers had type 2 diabetes. The patient was not abusing alcohol and did not have a history of pancreatitis. Three years prior to this admission the patient had been diagnosed elsewhere with type 2 diabetes, for which she had been on metformin and a small dose of insulin glargine. Two months after stopping her insulin glargine she developed her first episode of DKA while visiting our town. DKA, was diagnosed on the basis of arterial pH 7.03, blood glucose level 25.9 mmol/L, bicarbonate level of 5 mmol/L and positive urinary ketones. It was felt that infected skin lesions may have precipitated the DKA. Eleven days later, she was discharged on metformin 250 mg twice daily and a falling dose of insulin glargine (26 units a day). She was then lost to follow-up in our centre, but apparently soon after did not require insulin and maintained adequate gylcaemic control for 18 months until just prior to her next admission solely on metformin 1 g twice daily. The next admission for DKA occurred while living in a city. She was discharged on insulin but Continue reading >>

In Depth | Trulicity: New Once-weekly Treatment For Type Ii Diabetes

Dulaglutide is a long-acting GLP-1 receptor agonist. It improves glycaemic control by lowering fasting, pre-meal and postprandial glucose concentrations. The antihyperglycaemic effect starts after the first dose and is sustained throughout the once-weekly dosing interval, as a result of the prolonged half-life of 4.7 days.1 The safety and efficacy of dulaglutide were evaluated in six randomised, controlled, phase III trials involving 5,171 patients with type II diabetes. The primary endpoint in all studies was mean change in HbA1c.1 Treatment with dulaglutide monotherapy (1.5mg once weekly) resulted in an HbA1c reduction of -0.78% at week 26 compared with a reduction of -0.56% for metformin (1.52g daily). Once-weekly dulaglutide at either dose (750 microgram and 1.5mg) was superior to metformin in terms of HbA1creduction at 26 weeks (p<0.0025 for both).2 Another study compared dulaglutide 1.5mg and 750 microgram with sitagliptin 100mg daily in metformin-treated patients with inadequate glycaemic control. At week 52, both dulaglutide doses produced superior glycaemic control to sitagliptin, with mean HbA1c reductions of 1.1% and 0.87% versus 0.39%, respectively (p.0.001 for both comparisons).3 In a non-inferiority study, patients with inadequately controlled diabetes receiving metformin (1.5g/day) were randomly assigned to receive once-weekly dulaglutide 1.5mg (n=299) or once-daily liraglutide 1.8mg (n=300). Dulaglutide showed non-inferiority to liraglutide for HbA1c reduction at week 26.4 Dulaglutide was compared with insulin glargine in patients receiving metformin and a sulfonylurea . Dulaglutide 1.5mg was superior to insulin glargine in lowering HbA1c at week 52 and the benefit was maintained until trial end (78 weeks). In addition, dulaglutide 750 microgram was non Continue reading >>

Insulin Vs. Metformin Treatment

Diabetes affected 7.8 percent of the American population in 2007. Diabetes has several causes. Type 1 diabetes, previously called juvenile diabetes, caused by failure of the pancreas to produce insulin, affects 5 percent to 10 percent of people with diabetes, while Type 2 diabetes, previously called adult-onset diabetes, accounts for most of the rest, according to the National Institute of Diabetes and Digestive and Kidney Disorders. Different drugs are used to treat diabetes, depending on the cause and severity of the disease. Insulin, an injectable medication, and metformin, an oral medication, have different actions. Video of the Day The purpose of both insulin and metformin is to lower blood glucose levels. Insulin injections replace the insulin your body can no longer make when the cells in the pancreas cease to function. Metformin is an oral hypoglycemic, which lowers blood glucose levels by decreasing the liver’s output of glucose. Metformin also increases insulin sensitivity, and improves not only blood glucose levels but also lipid levels and often results in weight loss. Of all diabetics, 14 percent take insulin only, 57 percent take oral medications only and 14 percent take a combination of both, the NIDDK reports. Oral hypoglycemics are used only in Type 2 diabetes, because Type 1 diabetics make little or no insulin, so reducing the glucose levels produced by the liver won’t reduce blood glucose levels. Without insulin, glucose can’t enter cells and remains in the bloodstream. While all Type 1 diabetics take insulin, some Type 2 diabetics also need insulin in addition or instead of oral hypoglycemics such as metformin. Insulin, which must be injected, comes in several forms and doses, and can have rapid or slow onset. Diarrhea, the most common side eff Continue reading >>

Latent Auto-immune Diabetes Of The Adult

With the epidemic of diabetes at full swing in America right now, its a good time for naturopathic physicians to update themselves on the different types of diabetes. In particular, its pertinent for NDs to learn about a common type of diabetes that has not been heard of by most physicians, including most MDs. Latent Auto-Immune Diabetes of the Adult (LADA) is not well known. LADA is an auto-immune process against the beta cells of the pancreas, but the destruction of the organ occurs very slowly, not quickly as in classic Type I. As a result, patients with LADA can be treated without insulin for years, and when it begins to be needed, doses are very low compared to injecting either Type I or Type II patients. LADA patients are often misdiagnosed as Type II patients, as onset typically occurs during the mid-30s to -40s age range and insulin is rarely needed initially. In fact, recent studies show that 15%-20% of Type II patients are actually LADA patients. Thus, because many doctors are unaware of LADA, Type II is the only other option for diagnosis, though LADA patients are invariably lean, which makes a Type II diagnosis suspicious at best. They do not have insulin resistance. The LADA patients Ive seen were women and diagnosed originally with Type II, even though none of them had any truncal obesity or signs of insulin resistance. Their ages at diagnosis ranged from 37 to 45 years. There is no family history of diabetes Type I or II in LADA patients. LADA patients will be diagnosed through elevated blood sugar levels, both fasting and post-prandially. They do not present with ketoacidosis as a Type I patient does; their blood sugar numbers are not that high. Unlike Type I patients, they do not have to be hospitalized right away to stabilize their condition. However, Continue reading >>

Best Treatments For Type 2 Diabetes

At-a-glance Six classes of oral medicines (and 12 individual drugs) are now available to help the 25.8 million people in the U.S. with type 2 diabetes control their blood sugar when diet and lifestyle changes are not enough. Our evaluation of these medicines found the following: Newer drugs are no better. Two drugs from a class called the sulfonylureas and a drug named metformin have been around for more than a decade and work just as well as newer medicines. Indeed, several of the newer drugs, such as Januvia and Onglyza, are less effective than the older medications. Newer drugs are no safer. All diabetes pills have the potential to cause adverse effects, both minor and serious. The drugs’ safety and side effect “profiles” may be the most important factor in your choice. The newer drugs are more expensive. The newer diabetes medicines cost many times more than the older drugs. Taking more than one diabetes drug is often necessary. Many people with diabetes do not get enough blood sugar control from one medicine. Two or more may be necessary. However, taking more than one diabetes drug raises the risk of adverse effects and increases costs. Taking effectiveness, safety, adverse effects, dosing, and cost into consideration, we have chosen the following as Consumer Reports Best Buy Drugs if your doctor and you have decided that you need medicine to control your diabetes: Metformin and Metformin Sustained-Release — alone or with glipizide or glimepiride Glipizide and Glipizide Sustained-Release — alone or with metformin Glimepiride — alone or with metformin These medicines are available as low-cost generics, costing from $4 to $35 a month. If you have been diagnosed with diabetes, we recommend that you try metformin first unless it's inappropriate for your hea Continue reading >>

The Lada Epidemic. What's Going On Here?

A surprising number of people who are joining the online diabetes community after recent diagnoses are people who have been diagnosed with a new form of diabetes which is called LADA, which stands for Latent Autoimmune Diabetes of Adults. It is neither Type 1 or Type 2, but is often called "Type 1.5." Typically, a person with LADA goes to the doctor sometime after the age of 35 and is told they have type 2 diabetes. They are put on oral drugs like metformin or Avandia and almost nothing happens. If they read up online and cut their carbs their blood sugars do improve, but even so, over time they continue to rise. Within an average of four years, they have no insulin production left at all. At this point they must go on insulin. But the Lantus-only regimens most doctors prescribe--the ones that work well for many people with Type 2 diabetes--do not stop the inexorable rise in their blood sugars, and eventually they end up needing the full basal/bolus treatment that Type 1s use. That's because LADA is really a slow-developing form of Type 1. The body mounts an immune attack on the pancreas and wipes out the insulin producing cells. The difference between LADA and classic Type 1 is the speed with which this happens. In young Type 1s a person can go from normal to completely whacked in a week. People with LADA may take up to a decade to lose all their insulin-secreting capacity. People with LADA are often thin, so if you are thin and are told you have Type 2 diabetes, you should demand the antibody tests that are used to diagnose LADA. The antibodies tested for are: GAD antibodies, Islet cell antibodies, and more rarely, tyrosine phosphatase antibodies. But not all people with LADA are slim. People with defective autoimmune genes are also prone to get thyroid disease and rh Continue reading >>

9 Surprising Truths You Haven't Heard About Diabetes

9 Surprising Truths You Haven't Heard About Diabetes Cutting-edge research and studies are changing how this disease (which strikes 29 million Americans) is classified, treated and prevented. 1. Diabetes can be prevented with a pill. Youve probably heard the name of this drug before. Its called metformin and its a common first-line defense for type 2 diabetics. But what you havent likely heard is that by reducing glucose production by the liver and improving insulin resistance, metformin can help keep prediabetes from turning into full-blown diabetes. Its safe and effective, yet one study revealed doctors only prescribe the drug to about 8% of those the American Diabetes Associations guidelines recommend it for: prediabetics who are under age 60, severely obese or have a history of gestational diabetes. Experts surmise its being underprescribed because many doctors and patients seem to be unaware of the drugs effectiveness, and a spate of studies have found that lifestyle changes were more effective than metformin at preventing diabetes. An aversion to daily medicine could also make some people refuse the prescription, explains Kevin Goist, MD, an assistant professor of internal medicine at The Ohio State University Wexner Medical Center . However, the Centers for Disease Control and Prevention estimates that 15% to 30% of prediabetics will progress to type 2 within five years. For those who are unable to change diets and incorporate more physical activity into their lives, metformin is a realopportunity to prevent or delay the onset of diabetes, says endocrinologist Tannaz Moin, MD, the studys lead author and an assistant professor at the David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System . 2. Even slim adults get diabetes. Its been c Continue reading >>

5 Ways Massage Improves Diabetes Care

In the U.S., more than 29 million people live with diabetes. Among U.S. seniorspeople aged 65 years and older11.8 million people, or 25 percent, have diabetes, according to the American Diabetes Association . November is National Diabetes Month, a time to become more knowledgeable about this increasingly common disease and how massage can help people who have diabetes. Broadly defined, diabetes mellitus features elevated blood sugar levels and a failure to produce or utilize insulin. There are several varieties of this condition: Type 1 features an autoimmune destruction to pancreatic beta cells. Formally called insulin-dependent diabetes and/or juvenile diabetes. Type 2 is a more common type than Type 1, and features a failure of insulin production or inability to utilize what insulin the body does create. Formally called non-insulin-dependent diabetes. Type 1.5 involves signs and symptoms of both Type 1 and 2. Usually affects people later in life; some doctors believe some patients with Type 2 actually have this type. Gestational occurs when the fetus compromises the mothers ability to utilize sugar properly. Insipidus features kidney failure or pituitary gland dysfunction. The two most common causes of diabetic conditions are obesity and sedentary lifestyle, according to the American Diabetes Association. Other causes include genetics, trauma, or glandular dysfunction throughout the body. The most common signs and symptoms include polyuria, or excessive urination; polydipsia, or excessive thirst; fatigue, lethargy, neuropathy, or lower-limb nerve affectation; and paresthesia, or a burning or prickling sensation. The most common complications include heart and vascular conditions, dental disease, amputations, kidney disease, vision challenges and immobility. Among th Continue reading >>

Www.drmcdougall.com

The Latest Scams from the Diabetic Industry Big Pharma and Big Medicine have faced many huge challenges over the past years to keep their cash cows—people with type-2 diabetes—each forking over an average of $13,700 annually (approximately 2.3 times more than what expenditures would be in the absence of diabetes). This financially rewarding system works well until the blood-sugar-lowering medicines, along with the gadgets and tests they rely on, are proven to be useless and dangerous. Unfortunately for the patients, industry fights back, defending their treasure-trove by hiring pricey medical experts, factoring in expected lawsuits, and exaggerating the benefits and minimizing the harms of their products. Metformin Is Simply the Least Harmful Metformin (Glucophage) has been commonly prescribed for over 60 years to lower blood sugar. More than half of the 58 million Medicare claims for medications to treat people with non-insulin-dependent diabetes in 2014 were for this class of oral medication. Almost all physicians these days practice under the belief that metformin is the first-line medication for diabetes because it not only lowers blood sugar but has multiple additional benefits, including fewer heart attacks and strokes (cardiovascular events) for the patient. However, the truth is that since 2001 the evidence supporting the cardiovascular benefits of diabetic medications has been recognized as seriously flawed. Furthermore, the universal claims that metformin reduces cardiovascular disease are primarily based on a small subgroup of patients (n = 342) from the 1998 United Kingdom Prospective Diabetes Study (UKPDS) conducted more than three decades ago. Honest researchers have made multiple unsuccessful attempts to overturn dogma surrounding this "first-line med Continue reading >>

Diet Diary: You Can’t Blame Family History For Type 1.5 Diabetes

We all know that diabetes is of two kinds – type 1 diabetes also called juvenile diabetes or IDDM (Insulin dependent diabetes mellitus), which occurs in childhood, and type 2 diabetes also called adult/ maturity onset or NIDDM (non-insulin dependent Diabetes mellitus), which as the name suggests happens in adults and is associated with poor lifestyle and obesity. Now, a new type of diabetes, called LADA (Latent Auto-immune Diabetes in adults) or Type 1.5 diabetes has been recognised. It falls in between type-1 and type-2 diabetes. LADA, also called MODY (maturity onset diabetes of the young), is a form of childhood diabetes that occurs in adults over 30 years of age. In this type of diabetes, the body destroys its own insulin producing beta cells of the pancreas. LADA was first discovered in 1993 to describe slow onset childhood diabetes (type-1) in adults. Nearly 80 per cent people with LADA are initially misdiagnosed as having type-2 diabetes. People with LADA are usually non-obese, lean and even underweight, while some may be overweight or mildly obese. Often people with LADA, may or may not have family history of type-2 diabetes, but may have a family history of other auto-immune conditions such as thyroid, arthritis, gluten-related disorders and celiac disease. They test positive for certain auto-antibodies that are not present in type-2 diabetes. Treatment for LADA may involve diet, exercise and medication initially but eventually insulin therapy is needed. Although LADA seems to initially respond to lifestyle and medication as in type-2 diabetes, it will not halt or slow the progression of beta cell destruction and people will eventually become insulin dependent. Dietary recommendations to manage LADA include slowing progression of the disease, management of bo Continue reading >>