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January 31, 2008

Hyperglycemia and DKA, Pills for Diabetes

Question from Gujarat, India:

I have had diabetes for five years. In spite of taking 500 mg/d metformin three times a day, my blood sugars are sometimes 200 mg/dl [11.1 mmol/L] due to overeating. My A1c was 6.7. My random microalbumin in one sample was 73.4 while creatine was normal. My lipids were almost normal, but in need of improvement. What further tests should I have? Do you have any suggestions as to what I should do with my diet? Are there any other medications I should be taking? I plan to discuss your answer with the doctor at my small medical center.

Answer:

There are several points to make about the description of your situation.

Your hemoglobin A1c is pretty good. Most assays in the U.S. are normal at less than 6.0%. It is possible to increase the metformin to 850 mg three times per day in order to maximize therapy on the single drug.

I do not know what the units in which you are reporting your random urine for albumin:creatinine. We usually report the ratio of albumin:creatinine. Values that are less than 30 mcg/mg creatinine are normal. Sometimes it is just the urine albumin concentration that is reported and that is less helpful. If two random samples of albumin:creatinine are more than 30 mcg/mg cr, I would usually recommend initiation of treatment with an ACE inhibitor and increase the dose to normalize the albumin: creatinine ratio.

All patients with type 2 diabetes should probably be on a statin to lower LDL cholesterol.

You should also be on 81 mg of aspirin per day.

JTL