Should we get rid of everything but insulin and metformin?

[spacecowgirl]

---

Members do not see this ad.

I'm starting to honestly wonder.

Actos and bladder cancer, we know what happened to Avandia, Victoza and thyroid cancers, Byetta and pancreatitis, Januvia and pancreatitis...I know some of these are case reports, animal data and alerts, but I can't help but wonder if it's worth it.

Maybe it's the people I tend to see in clinic, but I know they're going to be on insulin anyway, why mess around with this stuff?

What do you think?

 

[amox]

I'm starting to honestly wonder.

Actos and bladder cancer, we know what happened to Avandia, Victoza and thyroid cancers, Byetta and pancreatitis, Januvia and pancreatitis...I know some of these are case reports, animal data and alerts, but I can't help but wonder if it's worth it.

Maybe it's the people I tend to see in clinic, but I know they're going to be on insulin anyway, why mess around with this stuff?

What do you think?

NIDDM patients would all smell like fish.

 

[npage148]

They all should anyways if you even half-heartily follow guidelines

 

[spacecowgirl]

They all should anyways if you even half-heartily follow guidelines

Why do you think it doesn't happen?

I think it has a lot to do with 1) PCPs being hesitant/scared to start insulin and 2) pushback from patients about starting insulin.

 

[PumpkinSmasher]

Why do you think it doesn't happen?

I think it has a lot to do with 1) PCPs being hesitant/scared to start insulin and 2) pushback from patients about starting insulin.

Hit nail on the head in my opinion. Insulin and metformin are the true work horses.

 

[npage148]

Sorry I was unclear.

I meant to say that all NIDDM should smell like fish (be on metformin) if anyone is taking a glance at the guidelines.

But in regards to insulin and NIDDM, i think it's becasue DM education is so poor and the stigma with insulin (ie. my mom went on insulin and then got a BKA). We (all health care providers) need to promote the benefits of insulin to type 2s and stress how poorly oral meds do in controlling BG. But the easy way is to toss pills at these patients becasue they don't "need" insulin and they can kinda be controlled with oral meds. I don't think Dr's are scared, but they don't have the time to have a 30min convo about the benefits of insulin to a patient who really isn't ready to take control of their health

If I was type 2 and metformin/lifestyle wasn't cutting it, I would be asking for a humalog pen. Dosing for type 2 really is not the complicated especially with the pens and insulin analogs

 

[pfaction]

May I ask why not oral sulfonylureas before actual insulin?

(or meglinitides before eating, which should put them in routine to start insulin)

 

[npage148]

May I ask why not oral sulfonylureas before actual insulin?

(or meglinitides before eating, which should put them in routine to start insulin)

Doesn't address the pathogensis of type 2 (but neither does insulin), further stresses and reduces beta cells mass, generally don't control BG that well, hypoglycemia and difficulty titrating dose as needed (based on meals).

 

[Praziquantel86]

I think the issue is different depending on which point of view you look at the issue from. For a patient, insulin seems like they're admitting defeat, not to mention the big pain in the neck it can be. It can't all be fear of injection, because a lot of people who refuse insulin end up on Victoza or Byetta.

From a providers perspective (at least well-informed providers), I think it might be a desire to treat the underlying disease process rather than just go around it. The DPP-IV inhibitors and GLP-1 agonists do this, at least in theory. What we need are better versions of these drugs and more research into the underlying causes of T2DM.

 

[spacecowgirl]

If you have someone with an A1c of 8% on met + sulf, adding Byetta and Victoza probably won't get you where you need to be (or TZDs for that matter). Now with these new FDA warnings on GLP-1 and DPP-IVs, it seems like it makes more sense to skip to insulin. IIRC, the beta-preservation qualities of GLP-1 and DPP-IV agents have not been proven. Correct me if I'm wrong.

Do we roll with the resistance or try to educate? I think we have a pretty good understanding about the pathogenesis of NIDDM, but you're right that working on these mechanisms is a great thing but the currently available agents don't seem as promising as they did 4-5 years ago.

Anyone know if there are studies on starting basal insulin earlier and how that might affect the disease process? If I had to choose between something that is an analog of a substance naturally occuring in humans vs lizard spit, I'd choose the former but that's just me

Again, for me I think - why put people through years of trying combo therapy when they are hopefully going to end up on insulin because hopefully they will live long enough to get there.

 

[iFarm]

Being on insulin would be horrible. Try testing your blood sugars 3x/day for a couple weeks (FYI... it's only fun the first few times). Then imagine having to stick yourself with insulin on top of that (A great preceptor taught me this lesson).

Administration method is very important to patients. We're talking about a life long therapy... so it's a quality of life issue. And not everyone is going to be able to use a pump.

 

[Carboxide]

Being on insulin would be horrible. Try testing your blood sugars 3x/day for a couple weeks (FYI... it's only fun the first few times). Then imagine having to stick yourself with insulin on top of that (A great preceptor taught me this lesson).

Administration method is very important to patients. We're talking about a life long therapy... so it's a quality of life issue. And not everyone is going to be able to use a pump.

Considering that Type II DM can be well controlled and sometimes completely "cured" with weight loss and lifestyle changes, I'd disagree. Perhaps a less convenient treatment would keep people from thinking, "Oh, it's ONLY Type II. No big deal. Just take a pill."

 

[Pharmacy Kid]

Anyone know if there are studies on starting basal insulin earlier and how that might affect the disease process? If I had to choose between something that is an analog of a substance naturally occuring in humans vs lizard spit, I'd choose the former but that's just me

http://www.medscape.com/viewarticle/712982

Peace

 

[All4MyDaughter]

I had gestational diabetes and controlled it with metformin and Lantus. I didn't have any problems with excessive weight gain. Very effective, easy regimen. Insulin injections are nothing. Don't even hurt. The fingersticks are annoying, but you get used to them and they become habit. If I end up with Type 2 someday, I'll go back to that rather than messing around with all the other orals.

In my DM rotation, I saw so many patients on complicated, expensive regimens that really weren't getting them enough A1C lowering. But people are afraid of insulin. We can help remove that stigma by educating patients. 👍

 

[Sparda29]

Being on insulin would be horrible. Try testing your blood sugars 3x/day for a couple weeks (FYI... it's only fun the first few times). Then imagine having to stick yourself with insulin on top of that (A great preceptor taught me this lesson).

Administration method is very important to patients. We're talking about a life long therapy... so it's a quality of life issue. And not everyone is going to be able to use a pump.

Compared to future quality of life issues such as kidney failure and foot ulcers? I think if you convey that message to the patient they'd be willing to go on insulin therapy.

 

[meister]

i am a big fan of glargine insulin and insulin therapy in general but you would not believe how hesitant most lay people are at starting insulin therapy, even if you spend 20 minutes with them explaining the benefits.

 

[R xxx]

I have worked with a lot of patients that would just flat out refuse to use insulin. No matter what you tell them, they still think it's the last choice of treatment and their disease is getting worse. The problem with diabetes is that most of them don't feel bad having high blood sugar. I know someone personally that claims everything causes her to have hypoglycemia despite BS in the high 200's after taking meds. She also stated that she would rather go blind or have other complications than to take insulin. How do you treat someone like that? While I agree that Metformin and Insulin are the best options, convincing those patients otherwise is another story.

 

[genesis09]

The insulins of today are so much better than the old ones. They are much cleaner and don't have to worry about the allergic reactions sometimes associated with the porcine/cow based insulins. Also, the needles are smaller and are silicon coated. People are afraid about sticking themselves with a needle. Honestly, the pain associated with glucose testing is much more than insulin.

 

[npage148]

The insulins of today are so much better than the old ones. They are much cleaner and don't have to worry about the allergic reactions sometimes associated with the porcine/cow based insulins. Also, the needles are smaller and are silicon coated. People are afraid about sticking themselves with a needle. Honestly, the pain associated with glucose testing is much more than insulin.

Finger sticks suck even with the new lancets. for me the worse part of giving blood is the HCT check needle stick. HATE IT. But yeah, we gave ourselves a saline shot in school, couldn't even feel the needle. THey are that painless now, it was pretty amazing

 

[spacecowgirl]

I went to a conference where they suggested that if you are thinking of starting someone on insulin, the very first thing to do in the visit is have them give themselves a saline shot and you give yourself one. Right away before they have time to get anxious about it. Wouldn't work for every patient (nothing does) but I will use that at some point.

Having done glucose testing, SQ shots and IM shots, and POC INR testing, I'll take SQ every time. Have you seen the micro and nano pen needles? Crazy small.

 

[rxlea]

My preceptor told me to do the saline shot on myself and have the patient do it during my IPPE. It works. I like doing diabetes education. I think I want to go the CDE route.

 

[iFarm]

I had gestational diabetes and controlled it with metformin and Lantus. I didn't have any problems with excessive weight gain. Very effective, easy regimen. Insulin injections are nothing. Don't even hurt. The fingersticks are annoying, but you get used to them and they become habit.

No offense A4MD, but that's n=1. Also, gestational diabetes is not lifelong. AND you're a highly educated healthcare professional doing what was best for herself and her unborn child. Doesn't represent the DM patient population very well.

Compared to future quality of life issues such as kidney failure and foot ulcers? I think if you convey that message to the patient they'd be willing to go on insulin therapy.

Try conveying that message to them. I think you'll be surprised.

i am a big fan of glargine insulin and insulin therapy in general but you would not believe how hesitant most lay people are at starting insulin therapy, even if you spend 20 minutes with them explaining the benefits.

Yes!

Considering that Type II DM can be well controlled and sometimes completely "cured" with weight loss and lifestyle changes, I'd disagree. Perhaps a less convenient treatment would keep people from thinking, "Oh, it's ONLY Type II. No big deal. Just take a pill."

Seriously? Injections will scare patients into diet/exercise? Maybe 1 in 10000. But I'm thinking this 'only metformin+insulin' idea might lower compliance in many more than that. And that means even less healthy diabetics. Treatment guidelines should be geared towards helping the masses, not that 1 guy that needs fear of a needle to push him onto a treadmill.


I guess all I was trying to say was... No, I don't think we should get rid of everything but insulin and metformin.

 

[PharmaTope]

Why do you think it doesn't happen?

I think it has a lot to do with 1) PCPs being hesitant/scared to start insulin and 2) pushback from patients about starting insulin.

the malpractice setups in this country are to blame.

the heart of all problems with the healthcare system stem from law suits. unnecessary scans, increased bills, unpaid, rolled onto all other patients


insulin is avoided bc patients are dumb, will go hypo, will then sue the doctor saying they didnt give the right education, the right dose, etc etc

docs wanna avoid lawsuits so they say screw the insulin.

 

[spacecowgirl]

Typical patient - met + sulfonylurea. A1c 8.2% (goal of <7%). HTN, high cholesterol, CrCl= 70 ml/min, metabolic syndrome, won't make any real lifestyle changes. What do you add next?

 

[pfaction]

I have not taken the diabetes portion of my class. I was going to say ARB/ACE inhibitor to protect the kidneys and heart/HTN.

 

[owlegrad]

Typical patient - met + sulfonylurea. A1c 8.2% (goal of <7%). HTN, high cholesterol, CrCl= 70 ml/min, metabolic syndrome, won't make any real lifestyle changes. What do you add next?

I have not taken the diabetes portion of my class. I was going to say ARB/ACE inhibitor to protect the kidneys and heart/HTN.

I think she meant what do you add to control blood sugar. An ACE-i is a good addition though, as is a statin.

 

[Old Timer]

ishould we get rid of everything but insulin and metformin?
What do you think?

yes​

 

[spacecowgirl]

I think she meant what do you add to control blood sugar.

Yes.

 

[dingerx]

Typical patient - met + sulfonylurea. A1c 8.2% (goal of <7%). HTN, high cholesterol, CrCl= 70 ml/min, metabolic syndrome, won't make any real lifestyle changes. What do you add next?

Man! 8.2 would be a gem of a pt. In low income clinic I wasn't seeing anybody less than 9. Still, with metabolic syndrome,
lantus HS
lispro
metformin maxed
enalapril and HCTZ
generic statin (not simvastatin at 80)
fish oil OTC at 2-4 gm/day dtd
and of course, in vain, put the smokes, chips, and beer down!