March 19, 2007
Pills for Diabetes, Type 2
Question from Sunnyside, Washington, USA:
I am writing to ask when the ADA started recommending that all type two diabetics be put on metformin along with diet and exercise at diagnosis, as indicated in your previous response. Is this regardless of what your fasting level is or what your A1c value is? I am a 47-year-old female, diagnosed with type 2 in August 2001. I am not on any medications for diabetes, but I am taking 20 mg lisinopril for blood pressure, 40 mg Zocor for cholesterol, and a baby aspirin each day. I have lost about 25 pounds since my diagnosis and eat healthier than I used to. I could stand to lose another 15 pounds, but the weight loss has come to a standstill for perhaps a year and a half. Luckily, I haven't re-gained any of the weight I lost, though. I was diagnosed with type 2 about five and a half years ago, based on an Oral Glucose Tolerance Test (I was not pregnant). The results of that test were: fasting - 97 mg/dl [5.4 mmol/L]; one-half hour - 220 mg/dl [12.2 mmol/L]; one hour - 218 mg/dl [12.1 mmol/L]; and two hours - 219 mg/dl [12.2 mmol/L]. At the three hour mark, I was down to 115 mg/dl [6.4 mmol/L]. Lately, my fastings have been between 85 mg/dl [4.7 mmol/L] and 104 mg/dl [5.8 mmol/L]. They are mostly in the 90s mg/dl [5.0 to 5.5 mmol/L], with a few in the low 100s [5.6 to 5.8 mmol/L]. My A1cs were very good until about a year ago, in December 2005, when it was up to 5.7%. Then, in December 2006, it was up again, to its highest, 6.08%. I do know that, sometimes, my postprandial levels go too high. Sometimes, depending on what I eat, of course. I could be at 208 mg/dl [11.6 mmol/L] at one hour, but down under 140 mg/dl [7.8 mmol/L] at two hours. The highest I've seen it was at 255 mg/dl [14.2 mmol/L] when I had a touch of the flu bug. Again, this was at one hour after eating. At two hours, I was down to 123 mg/dl [6.8 mmol/L]. So, given your statement, when do most doctors put patients on medication? I don't seem to be the "typical" diabetic with the normal fasting levels, so it's confusing. I'd like to know the answer to my first question, then, of course, my other questions before my next doctor's appointment so I have two opinions.
This is a new recommendation based on consensus statements from American and European specialty recommendations. The publications for these consensus statements appeared in 2006 so that the recommendations were incorporated into the 2007 practice recommendations for the first time this year. I believe the strongest reason for using the metformin is the high rate of unsatisfactory control or progression with just lifestyle modifications alone.
[Editor’s comment: Please review our previous questions as we have added an additional response from a second endocrinologist. Make sure you discuss this with your diabetes team/endocrinologist.