Forums » Open clinical » Diabetes » What is your favourite oral anti-diabetic drug beyond metformin?
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 11/5/2011 8:39 AM BST
on bmj.com
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Posts: 566
First: 9/10/2009 Last: 13/3/2013 |
Hypoglycemia (diagnosed by classic Whipple's triad) is a constant side-effect of any of the sulfonylureas, and glipizide is no exception. However, what is important is to tailor the dose of such drugs, so that side-effects are minimized, or avoided. Hence, initially, a blood-glucose and a symptom log, and also counselling is essential, which will help to control hyperglycemia, with out the inherent drug's side effects of hypoglycemia. It’s my observation here that the most common cause of hypoglycemia is 'missed or delayed meals', and not the anti-diabetic drug dosage. Another terrifying trend causing hypoglycemia that I have been noticing here is ... a diabetic mixing alcoholic beverages. Interestingly, the signs of intoxication and hypoglycemia are almost similar, and this has to be kept in mind by the treating physician. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 13/5/2011 12:44 PM BST
on bmj.com
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Posts: 1
First: 13/5/2011 Last: 13/5/2011 |
I usually go as high as 1000mg twice a day on Metformin before adding a second drug. My drug of choice after metformin has always been a sulphonyurea titrated to get the best HBA1C with minimal side effects. Despite the recent additions of different medications to the treatment of type 2 DM, I still think these are the best first two drugs to use. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 13/5/2011 3:41 PM BST
on bmj.com
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Posts: 7
First: 13/5/2011 Last: 18/2/2012 |
When we diagnose a patient with T2DM, it is well known to us that the patient has already lost his or her 50% of total beta cell mass (UKPDS) and progressive loss of beta cells continues approximately at the rate of 4-5% per year despite intensive glycemic control by oral medications. I think when we start to treat a patient with T2DM, we need to be concerned about 2 important things; prevent hypoglycemia and preserve residual beta cell-mass. I think unless contraindicated, metformin should be the first line of oral anti-diabetic agents for its unique mechanisms of action. It reduces hepatic glucose production and increases insulin sensitivity in the peripheral tissue. All T2DM patients are associated with insulin resistance syndrome which, beyond dysglycemia, includes hypertension/prehypertension, dyslipidemia, obesity and other situations, the outcomes of endothelial dysfunction. Metformin is a unique agent to reduce endothelial dysfunction, restores bio-availability of NO hence reduces all cardiometabolic risks. Acta Diabetol. 2011 Mar 23.Br J Pharmacol.2011 May;163(2):424-37. doi: 10.1111/j.1476-5381.2011.01230.x.Metformin as monotherapy reduces hyperglycemia but most patients require dual agents. Same strategies; prevent hypoglycemia and preserve residual beta cell-mass should be applied during selection of second agent. Here physician should also be concerned about efficacy, side effect and financial factor and treatment strategy should be individualized.No doubt that a DPP-IV inhibitor is the best combination as such dual agent associated with less or zero hypoglycemia, helps to preserve residual beta cell-mass, no weight gain and least side effects. Some DPP-IV inhibitor like alogliptin offers round the clock elevated level of GLP-1 and GIP. So DPP-IV inhibitor should be the first choice as add on therapy to metformin but in daily practice it is not possible to go for such combination randomly only due to financial factor. I prefer pioglitazone as next add on agent in absence of contraindications; HF class III & IV (NYHA classification), acute liver diseases, obesity and osteoporosis. As TZDs, I suggest not prescribing rosiglitazone and I have stopped that since August 2007 after Nissen Wolski’s meta-analysis was published. Pioglitazone associated with stable beta-cell function (TRIPOD study) and also offers PPAR-alpha activity beyond its PPAR-gamma action. Of course pioglitazone increases body weight but to some extent we can accept it for the fact that such increase in body weight not due to increase in visceral fat but subcutaneous which is associated with higher adiponectin activity. Further more such increase in body weight usually stabilises after about one year of pioglitazone therapy.As the third choice, I prefer sulfonylurea (SU) specifically gliclazide the best I think among SUs.As my additional opinion, I usually prefer to go for basal insulin along with metformin if metformin monotherapy fails to achieve target. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 13/5/2011 3:45 PM BST
on bmj.com
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Posts: 220
First: 10/12/2010 Last: 1/6/2012 |
Depends upon profile of the patient. No contraindications to Pioglitazone?; Let us start pioglitazone. Very high blood sugar levels like 170-230 fasting; start sulfonyluria also. If paitent is paying from his pocket go for the cheapest like glibenclamide; otherwise other expensive ones can be selected. If there are contraindications for pioglitazone; then add pioglitazone only 7.5 mg od, as this dosage is supposed to be non-toxic adding some marginal benefit but mainly you will depend upon sulfonylurias. Acarabose could be added if patient is not obsessed with his abdomen; starting with 25 mg bid going upto 100 mg bid. This can bring down HBA1C 0.5 -1 % down, if you wish to avoid sulfonyl urias. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 13/5/2011 8:24 PM BST
on bmj.com
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Posts: 3
First: 7/1/2011 Last: 29/6/2011 |
Dear Joey, |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 14/5/2011 2:34 AM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
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 Dear CSM: As I mentioned before I am a big fan of gliclazide, for all the reasons (and studies) that I pointed out. And you are that either. Since about 5 years from now, I prescribe gliclazide, in the extended release formulation, which allows-me to communicate, and build empathy better with my patients, when I tell them just to take that pills only once a day, at breakfast. The traditional way of prescribing this reliable sulfonyurea obliged me to prescribe not only higher, but also, mostly of times twice a day doses. So, this is my question to you: Why do you still continue with the traditional way of prescribing gliclazide? All best to you, Joey
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 14/5/2011 6:13 AM BST
on bmj.com
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Posts: 15
First: 18/2/2010 Last: 25/8/2012 |
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 Glimipride is my next favorit drug after Metformin. Jyoti Parekh(India) |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 14/5/2011 9:13 PM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
In Response to Re: What is your favourite oral anti-diabetic drug beyond metformin?: In Response to What is your favourite oral anti-diabetic drug beyond metformin? : Higher doses of metformin. Posted by Dean Jenkins Dear D. Jenkins: Why are you running away from this question? Joey  |
Posts: 453
First: 29/4/2011 Last: 14/5/2013 |
This article is an update from the 2007 review sponsored by AHRQ. It reviews all 11 unique classes of type 2 medications approved in the United States, alone and in combination. The review summarized 140 clinical trials and 26 observational studies. The authors concluded that the available medications all lowered A1C similarly by about 1%. Efficacy was limited by the data available in that only short term outcomes were available and long term benefits in the prevention or delay in microvascular complications would have to be assumed based upon previous clinical trials. Further the authors did not feel that the evidence for the prevention or delay of macrovascular events in type 2 diabetes by lowering A1C was adequate to make that assumption.
As has been previously suggested by others and incorporated into most clinical guidelines, metformin was felt to be the best initial therapy both in terms of safety and efficacy. Metformin was also shown to reduce weight and LDL-cholesterol concentrations to a greater extent than pioglitazone, sulfonylureas and DPP-IV inhibitors. Other safety observations were the higher risk for hypoglycemia with sulfonylureas and the higher risk of congestive heart failure and bone fractures with the thiazolidinediones.
In terms of effectiveness the authors were unable to find evidence that when added to metformin any of the other classes of agents represented clear clinical superiority. The clinician is left with several choices when adding a second or even a third agent based upon his or her judgment of the patients relative risks of hypoglycemia, congestive heart failure and the adverse effects of weight gain. I might also add relative costs to these considerations as, in general, the newer the agent, the higher its cost. |
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Re: What is your favourite oral anti-diabetic drug beyond metformin?
posted at 16/5/2011 11:31 PM BST
on bmj.com
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Posts: 24
First: 14/5/2009 Last: 7/4/2013 |
I am not able to to formulate a favourite oral anti-diabetic drug beyond metformin. I even doubt if metformin is a safe and effective anti-diabetic drug. I looked at Chochrane and was not at all impressed of the effectiveness and safety of metformin. I missed the convincing result of an placebo controlled trial. I think of diabetis type 2 as an age-related metabolic disorder of glucose metabolism. I think that it is caused by an age-related degeneration of cells in the islands of Langerhans and that the degeneration of these cells is accompanied by occurence of free-radicals that can harm DNA. In the cells amyloid plaques are formed. These plaques are not toxic! They can be regarded as the ashes of a dangerous fire. The plaques contain amyloid. Amyloid is not toxic itself. The fire is toxic! Treatment should aim at the prevention of the fire, that is by anti-oxidative drugs. Zinc is such an anti-oxidative drug. Free-copper induces, catalizes, the oxidative formation of amyloid from pre-amyloid molecules. Therefore, in my opinion: if I look for an anti-diabetic drug I should search for a drug that is safe and effective in reducing the free-copper concentration in the blood, in order to reduce the catalysis of amyloid formation and the formation of free-radicals. I think that oral zinc therapy might be a good option and would mention the remarkable effect of oral zinc therapy on free-copper intoxication in the metabolic disorder of copper metabolism, that is hepatolentular degeneration in Wilson's disease. Zinc therapy, about 50 mg elementatary zinc, that is about 220 mg zinc sulphate, or about 3 times the normal daily zinc contend of meals, would probable be a sufficient dose. For Wilson's disease, Schouwink introduced in 1961 (50 years ago), with a global wide succes the dose of 3 times 200 mg zinc sulphate. For age-related macular degeneration, another age-related amyloid related degenerative disorder, 50 mg elementary zinc in a placebo controlled clinical trial was sufficient to induce a significant improvement of the vision. Zinc therapy might also be a good option for the prevention of free-copper related dementia in Alzheimer's disease. But we have to await the result of the clinical trial that is in preparation. Therefore, I hope that in the search for the favourite drug for prevention of type 2 diabetes zinc will also get the attention it deserves: a placebo controlled randomised clinical trial. |
Forums » Open clinical » Diabetes » What is your favourite oral anti-diabetic drug beyond metformin?
