March 5, 2004
Pills for Diabetes, Type 2
Question from Salt Lake City, Utah, USA:
My stepfather was recently diagnosed with type 2 diabetes after several fasting blood sugars iaround the 180 mg/dl [10.0 mmol/L]. His A1c was around 9. His physician placed him on Glucophage, 500 mg twice a day; Zocor, 40 mg four times a day; and Benicar, 20 mg four times a day. His blood pressure at time of his visit was 140/90, and his total cholesterol was 117, HDL 41, and LDL 61. I am questioning the addition of the Zocor. When I contacted the doctor about this, I was told that, according to research when a diabetic is placed on a statin, even with normal cholesterol, there is a 22 percent reduction in cardiac incidents. His liver function tests were elevated even before he began to take the Zocor. They weren’t horribly high, AST 55, ALT 91, and Bilirubin 2.7, but I still am wondering if this is standard practice or is it completely unnecessary? His CPK was normal, and he hasn’t experienced muscle fatigue. He has completely changed his diet and increased his exercise since the diagnosis kind of freaked him out, and he has lost about ten pounds in the last three weeks. Do you think he should forego the Zocor? I am afraid that it’s too many medications at once.
Answer:
Yours is a very timely question and refers to recommendations for clinical practice recently published by the American Diabetes Association in their publication, Diabetes Care. As diabetologists, we have also been thinking about this. The numbers your stepfather’s physician quotes are from an actual study, the Heart Protection Study (MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial). This study was published in the Lancet in June 2003. The Zocor dose of 40 mg per day is the dose used in the study. It is a new goal for our patients. Whether the clinical recommendation is maintained or not is still not clear. It will be up to his physician to monitor his liver enzymes on the medication. It is not really too many medications. These are common drug combinations used by our patients with type 2 diabetes.
JTL
