What is your favourite oral anti-diabetic drug beyond metformin?
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Diabetes
What is your favourite oral anti-diabetic drug beyond metformin?
Discuss any aspect of type I or type II diabetes mellitus here
We all know there´s a whole bunch of oral anti-diabetic drugs, with different safety&efficacy, plus side effects profiles. We are eager to know your favourite one to add on metfo
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What is your favourite oral anti-diabetic drug beyond metformin?
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What is your favourite oral anti-diabetic drug beyond metformin?
posted at 13/4/2011 5:06 PM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
We all know there´s a whole bunch of oral anti-diabetic drugs, with different safety&efficacy, plus side effects profiles. We are eager to know your favourite one to add on metformin as the second drug, or even if you just take this other drug as the number 1 for your patients. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 14/4/2011 7:21 AM BST
on bmj.com
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Posts: 32
First: 14/4/2011 Last: 28/9/2012 |
It is difficult to make a blanket statement.All of us in practice know that each patient is different.There may be someone with postprandial hyperglycemia after instituion of metformin and may do well with an alpha glucosidase inhibitor or a glitazone.There could be another with residual fasting hyperglycemia.I would generally choose between pioglitazone and a DPP4 inhibitor because neither of them in combination with metformin alone is likely to cause hypoglycemia.A DPP4 inhibitor possibly has a better safety profile and not likely to cause weight gain but generally the cost is higher. Let me also remind myself that many patients with residual hyperglycemia may be managed without addition of other drugs.I would use it as an opportunity to reiterate life style issues.Addition of curry leaves and cinnamnon can make a difference and so can salt reduction.Many may not agree with me and most patients also do not initially realise that blood sugar control may depend more on the salt in the diet than the sugar! |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 18/4/2011 3:10 AM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
Dear Saluja: Thanks for your comments, and the smart view regarding the role of salt (and hypertension) in diabetic macro and microvasular complications. Actually, the UKPDS 38 showed a higher risk reduction in all diabetic complications with strict blood pressure control than with intensive glucose control: www.bmj.com/content/317/7160/703.abstract. Regarding my favourite number 2 drug to add on metformin, I usually go in my practice along with the data from the ADVANCE Study: http://content.nejm.org/cgi/reprint/NEJMoa0802987v1.pdf. In that study with gliclazide as the add on drug to metformin and a follow-up of 5 years, there was a nice decrease in HbA1c of 0.67, with no major weight gain (mean: 0.7 kg), a significant reduction in microvascular complications such as worsening nephropathy, new onset microalbuminuria, and development of macroalbuminuria. It was amazing to see the very low number of hypoglycemic episodes, probably related more to the target HbA1c level than to the drug itself. Gliclazide, in my experience, can also be safely used in diabetics with renal insufficiency (CKD stages from 1 to 4), is cheap, has been on the market for long years, has a wide dose range from 30 to 120 mg, and allows me to prescribe other not so cheap medications to reduce, on an individual per patient basis, the global risk burden of my patients; according to the best available evidence that multiple risk factor intervention is what works better in diabetics, as showed in the STENO2 trial: For these reasons, I go on gliclazide as my favourite drug to add on metformin in most of my type 2 diabetic patients. The newer oral anti-diabetic drugs, glitazones included, have a long way to go in clinical practice to replace my preference for this sulfonylurea. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 5/5/2011 1:39 PM BST
on bmj.com
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Posts: 195
First: 14/1/2009 Last: 17/5/2013 |
In Response to What is your favourite oral anti-diabetic drug beyond metformin?: We all know there´s a whole bunch of oral anti-diabetic drugs, with different safety&efficacy, plus side effects profiles. We are eager to know your favourite one to add on metformin as the second drug, or even if you just take this other drug as the number 1 for your patients. Posted by Joey Rio Higher doses of metformin. 
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 6/5/2011 1:02 AM BST
on bmj.com
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Posts: 32
First: 14/4/2011 Last: 28/9/2012 |
How high would you go on metformin?Would the side effects of say 1000 mg metformin and 30 mg pioglitazone be more than 2000 mg of metformin? In clinical practice,I do not see much add on benefit of high doses of metformin in getting blood sugar control. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 9/5/2011 12:51 AM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
Hi Saluja! A little higher (2200 to 2550 mg) Metformin dose, I go only for BMIs above 35. And I really do not like the weight gain of Pioglitazone. Rosiglitazone I never use it anymore, because of all bad scientific evidence surrounding it, and also not to be sued by any of my patients or their families. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 9/5/2011 11:42 AM BST
on bmj.com
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Posts: 32
First: 14/4/2011 Last: 28/9/2012 |
In Response to Re: What is your favourite oral anti-diabetic drug beyond metformin?: Hi Saluja! Metformin I usually go (over several weeks) up to 1700 mg/day, and I can see an effect of further HbA1C lowering. A little higher (2200 to 2550 mg) Metformin dose, I go only for BMIs above 35. And I really do not like the weight gain of Pioglitazone. Rosiglitazone I never use it anymore, because of all bad scientific evidence surrounding it, and also not to be sued by any of my patients or their families. Posted by Joey Rio Thanks for your valued views.In my clinical practice,I have often used 2000 mg of metformin but not impressed much by the additional blood sugar lowering vis a vis 1000 mg.As for pioglitazone,even more than the weight gain,it is the edema which bothers me more.Nevertheless,both the problems are much less if I can convince my patient to restrict salt.Even though weight gain of about 2 Kg is almost universal,there is no increase in waist circumference. Even if one may have reservations on pioglitazone,addition of a dpp4 inhibitor to metformin is better than pushing metformin to greater than 1000 mg daily. I do remain grateful to you for your valued views and shall always keep the points raised by you when I choose the drug for my next patient.I shall be happy to exchange more notes on it as we generate more clinical experience. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 10/5/2011 4:08 AM BST
on bmj.com
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Posts: 566
First: 9/10/2009 Last: 13/3/2013 |
The treatment regimen, starting with 80 mg gliclazide plus 500 mg metformin once a day and titrated to the next dose level depending on the clinician's judgment, not exceeding a total daily dose of 320 mg gliclazide and 2000 mg metformin is an effective treatment for patients inadequately controlled on sulfonylurea or metformin alone. This combination of gliclazide with metformin achieves good glycemic control – FPG, ,PPBG, and HbA1C are significantly reduced. Moreover, the lipid profile also improves during the treatment period. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 10/5/2011 9:56 PM BST
on bmj.com
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Posts: 32
First: 14/4/2011 Last: 28/9/2012 |
In Response to Re: What is your favourite oral anti-diabetic drug beyond metformin?: The treatment regimen, starting with 80 mg gliclazide plus 500 mg metformin once a day and titrated to the next dose level depending on the clinician's judgment, not exceeding a total daily dose of 320 mg gliclazide and 2000 mg metformin is an effective treatment for patients inadequately controlled on sulfonylurea or metformin alone. This combination of gliclazide with metformin achieves good glycemic control – FPG, ,PPBG, and HbA1C are significantly reduced. Moreover, the lipid profile also improves during the treatment period. Posted by csm@csm It is a good regimen and risk of hypoglycemia is low but I have had patients going into hypoglycemia with it. |
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