Choose Diabetes Medication

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Initiation of your diabetes medication therapy is always based on your fasting blood-glucose level FBG), postprandial blood-glucose level (PPG) and A1C percentage.

The contribution of FPG to A1C is dominating in patients with poorly managed blood glucose. The contribution of FPG is about 70% in patents whose A1C is near by 10.2%. As the blood-glucose level improves, PPG contribution dominates to about 70% when the A1C values close by 7.3%. Postprandial hyperglycemia is also one of the earliest abnormalities of glucose homeostasis associated with type 2 diabetes and is markedly exaggerated with fasting hyperglycemia.

In one study, PPG monitoring has been shown to improve outcomes is gestational diabetes. However, it appears that FPG is somewhat better than PPG in predicting HbA1c, especially in diabetes type 2.

Two major group of diabetes drugs

There are two major groups of oral hypoglycemic drugs: sulphonylureas (SUs) and biguanides (BGs). SU act by stimulating insulin release from the beta cells and by promoting its action through extra pancreatic mechanisms. BG exerts their action by decreasing gluconeogenesis and by increasing the peripheral utilization of glucose.

If possible, choose sulfonylureas as an initial therapy in non-obese patients since they are cheaper as compared to the newer agents. Choose metformin as an initial agent for obese patients (i.e., those more than 120 % of their ideal body weight) or as an add-on therapy in patients who is not able to control with sulfonylurea. Alpha-glucosidase inhibitor may be an alternative to sulfonylurea or as add-on therapy to metformin in patients with uncontrolled blood glucose or significant renal dysfunction.

Over the past decade, a major interest in postprandial glucose (PPG) has emerged, because of new medications specifically targeting PPG. These include insulin analogs (lispro and aspart), insulin secretagogues (repaglinide and nateglinide), alpha-glucosidase inhibitors (miglitol and acarbose), and injectable amylin analogs and glucagon-like peptide receptor agonists.

Appropriate targeting of plasma glucose may help to reduce expenses and limit unnecessary testing and may help achieve glucose goals faster. Targeting fasting plasma glucose is more beneficial, when A1C results are very high. Whereas targeting postprandial glucose is more effective when A1C results are lower.

Oral Hyperglycemic Agents glucose lowering strength

Agent

Avg. FBG reduction (%)

Avg. PPG reduction (%)

Avg. A1C reduction (%)

Sulfonylureas

25 to 40

20

2.0

α-glucosidase inhibitors

10 to 20

40 to 45

0.5 to 1.5

Metformin

20 to 40

25

1.5 to 2.0

Steps in choosing correct diabetes medication

  • During diagnosis if your A1C level is less than 7% or fasting blood glucose less than 130mg/dl or 7.223 mmol/l, you can manage your diabetes without medication and with lifestyle changes (diet and exercise).
  • If your A1C level is 7% or fasting blood-glucose level of 130mg/dl or 7.223 mmol/l, you should start your diabetes treatment with a mono-therapy (single medication). Preferably, Biguanides ( Metformin) or Sulphonylureas is considering as a first-line diabetes mono-therapy.
  • If the mono-therapy failed to produce the result; that is your FBG stays in more than 130 mg/dl or 7.223 mmol/l (after 6 weeks of treatment) or A1C more than 7% (after 12 weeks), consider dual-therapy with the combination of two different classes of diabetes drug. Preferable choices are Metformin + Sulphonylurea, alternatively Sulphonylurea + Thiazolidinediones.
  • If the dual-therapy failed to produce the result; that is your FBG stays in more than 130 mg/dl or 7.223 mmol/l (after 6 weeks of treatment) or A1C more than 7% (after 12 weeks), consider triple-therapy with the combination of three different classes of diabetes drug. Preferable choices are Metformin + Sulphonylurea + Thiazolidinediones, alternatively Metformin + Thiazolidinediones + DPP4 or Metformin + Sulphonylurea + GLP1 or Metformin + Thiazolidinediones + GLP1 or Metformin + Sulphonylurea + basal insulin.
  • During diagnosis, if your A1C level is more than 9%, start dual-therapy with the combination of two different classes of diabetes drug. Preferable choices are Metformin + Sulphonylurea, alternatively Sulphonylurea + Thiazolidinediones.
  • If the dual-therapy failed to produce the result; that is your FBG stays in more than 130 mg/dl or 7.223 mmol/l (after 6 weeks of treatment) or A1C more than 7% (after 12 weeks), consider triple-therapy with the combination of three different classes of diabetes drug. Preferable choices are Metformin + Sulphonylurea + Thiazolidinediones, alternatively Metformin + Thiazolidinediones + DPP4 or Metformin + Sulphonylurea + GLP1 or Metformin + Thiazolidinediones + GLP1 or Metformin + Sulphonylurea + basal insulin.
  • During diagnosis, if your A1C level is more than 10 with severe symptoms, start metformin and insulin therapy. Reach your target value by increasing the dosage of both medications. Continue oral medication; additionally take intermediate or long acting insulin before bedtime with an initial dose of 0.2 U/kg or 0.9 U/Lb. Monitor FPG and accordingly adjust insulin by 2 to 4 units after at least 3 days. FPG target should be 72 mg/dl to 144 mg/dl (or 4 to 8 mmol/L) based on your health condition.

Never exchange your diabetes medicines with others

Each diabetes medication has different mechanism of action. Your doctor prescribes your medicines based on a complete understanding of your condition. Henceforth, exchange doctors if you must but never exchange your medicines.

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