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Post by agedhippie on Dec 19, 2018 7:00:53 GMT -5
It impacts 9.2 wording which will need to be changed to something like inhaled insulin or RAAs should be used to reduce hypos but inhaled insulin may provide better control. Putting afrezza first is a big jump. Its coming, there is no stopping it but will take time to move the borg.
My take is Dr. Kendall is clearly having an impact on the community and moving the ball. Lets see what he releases from the lost studies to support the T2s and what new studies may be need there.
Changing the current T2 "Treat to Fail" Standard which is a disgrace needs to change asap. The question is how many years is "asap" to the borg. When you include treatments for T2s which are not worth the risk for T1s I see big red flashing lights. The best word I have is "disgrace".
When you have to put together a Rube Goldberg chart to explain the "Treat to Fail Standard", that says it all and they should be ashamed of themselves. I think they will add inhaled insulin to 9.2, I doubt they will add the bit about better control without trial data. They put the "may reduce hypos" in the text, not in the recommendations for the same reason, currently it exists but is not statistically significant so there needs to be trial data before it makes the recommendations. Treat to Fail is always going to remain because a lot of people never reach the next step so there is the risk of over-treating. The CDC reckon only 13% (the insulin + oral group) of Type 2s progress to insulin and a fair percentage of that sample are probably basal only. It's one reason insulin has such a bad name as it looks like the end. I don't find the idea of some drugs being restricted to a particular Type being alarming as these are different diseases. If the better endos think something works they will use it regardless, my endo prescribed metformin off-label to Type 1s for years. Some lucky people get both Type 1 and Type 2. I though of the chart more as snakes and ladders....
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Post by peppy on Dec 19, 2018 7:09:33 GMT -5
It impacts 9.2 wording which will need to be changed to something like inhaled insulin or RAAs should be used to reduce hypos but inhaled insulin may provide better control. Putting afrezza first is a big jump. Its coming, there is no stopping it but will take time to move the borg.
My take is Dr. Kendall is clearly having an impact on the community and moving the ball. Lets see what he releases from the lost studies to support the T2s and what new studies may be need there.
Changing the current T2 "Treat to Fail" Standard which is a disgrace needs to change asap. The question is how many years is "asap" to the borg. When you include treatments for T2s which are not worth the risk for T1s I see big red flashing lights. The best word I have is "disgrace".
When you have to put together a Rube Goldberg chart to explain the "Treat to Fail Standard", that says it all and they should be ashamed of themselves. I think they will add inhaled insulin to 9.2, I doubt they will add the bit about better control without trial data. They put the "may reduce hypos" in the text, not in the recommendations for the same reason, currently it exists but is not statistically significant so there needs to be trial data before it makes the recommendations. Treat to Fail is always going to remain because a lot of people never reach the next step so there is the risk of over-treating. The CDC reckon only 13% (the insulin + oral group) of Type 2s progress to insulin and a fair percentage of that sample are probably basal only. It's one reason insulin has such a bad name as it looks like the end. I don't find the idea of some drugs being restricted to a particular Type being alarming as these are different diseases. If the better endos think something works they will use it regardless, my endo prescribed metformin off-label to Type 1s for years. Some lucky people get both Type 1 and Type 2. I though of the chart more as snakes and ladders.... TREAT TO FAIL. That does seem to be the regime. I would say with these orals, treat to kill is on the table as well. However, the treat to kill has been documented as standards of care. The GLP-1 thyroid cancer. SGLT2, weight loss and kidney damage, not to mention amputation; has been proven better for the type two. We human beings are stupid.
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Post by seanismorris on Dec 19, 2018 7:28:55 GMT -5
I think they will add inhaled insulin to 9.2, I doubt they will add the bit about better control without trial data. They put the "may reduce hypos" in the text, not in the recommendations for the same reason, currently it exists but is not statistically significant so there needs to be trial data before it makes the recommendations. Treat to Fail is always going to remain because a lot of people never reach the next step so there is the risk of over-treating. The CDC reckon only 13% (the insulin + oral group) of Type 2s progress to insulin and a fair percentage of that sample are probably basal only. It's one reason insulin has such a bad name as it looks like the end. I don't find the idea of some drugs being restricted to a particular Type being alarming as these are different diseases. If the better endos think something works they will use it regardless, my endo prescribed metformin off-label to Type 1s for years. Some lucky people get both Type 1 and Type 2. I though of the chart more as snakes and ladders.... TREAT TO FAIL. That does seem to be the regime. I would say with these orals, treat to kill is on the table as well. However, the treat to kill has been documented as standards of care. The GLP-1 thyroid cancer. SGLT2, weight loss and kidney damage, not to mention amputation; has been proven better for the type two. We human beings are stupid. I was going to go with “We human beings are insane” but I suppose “We human beings are stupid“ also works.
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Post by mango on Dec 19, 2018 7:53:48 GMT -5
Combination Therapy. (type two.) Although there are numerous trials comparing dual therapy with metformin alone, few directly compare drugs as add-on therapy. A comparative effectiveness meta-analysis suggests that each new class of noninsulin agents added to initial therapy generally lowers A1C approximately 0.7–1.0% (46). If the A1C target is not achieved after approximately 3 months and the patient does not have ASCVD or CKD, consider a combination of metformin and any one of the preferred six treatment options: sulfonylurea, thiazolidinedione, dipeptidyl peptidase 4 (DPP-4) inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist, or basal insulin; the choice of which agent to add is based on drug-specific effects and patient factors (Fig. 9.1 and Table 9.1). For patients in whom ASCVD, HF, or CKD predominates, the best choice for a second agent is a GLP-1 receptor agonist or SGLT2 inhibitor with demonstrated cardiovascular risk reduction, after consideration of drug-specific and patient factors (Table 9.1). For patients without established ASCVD or CKD, the choice of a second agent to add to metformin is not yet guided by empiric evidence. Rather, drug choice is based on avoidance of side effects, particularly hypoglycemia and weight gain, cost, and patient preferences (47). Similar considerations are applied in patients who require a third agent to achieve glycemic goals; there is also very little trial-based evidence to guide this choice. In all cases, treatment regimens need to be continuously reviewed for efficacy, side effects, and patient burden (Table 9.1). In some instances, patients will require medication reduction or discontinuation. Common reasons for this include ineffectiveness, intolerable side effects, expense, or a change in glycemic goals (e.g., in response to development of comorbidities or changes in treatment goals). See Section 12 “Older Adults” for a full discussion of treatment considerations in older adults. ------------------------------------------------------------------------------------------------------------------------------------------------------------ The standards of care seem to be hot on the SGLT2. I am not sure how it got the cardiac improvement. the only thing I can think of is an improvement in congestive heart failure due to the diuretic effect/water loss of SGLT2. Amazing to me is not mentioned, love your number miss your legs. The greater threat of amputation does not seem to be mentioned. Can we ask ourselves, how can this be? You go to the doctor, you are told you have a high blood glucose. Metformin started. Three months later SGLT2 started. initial weightloss. keep taking it. soon enough your toes are not getting enough oxygen and glucose to complete the Kreb's cycle. Next thing you know, more weight loss, your foot is gone. Be still my heart. you know the drill, may your heart be still Metformin Triple Therapy Afrezza Therapy Fly like a bird my heart, the SoC is criminal
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Post by peppy on Dec 19, 2018 8:48:21 GMT -5
Mango, what I see in the above charts. Chart C specifically, it looks like it took 12 days and 1500 mg metformin a day and two additional oral drugs to turn off the liver at night. Chart D, and then the liver got used to the medications.
1600 cal a day.
too much fat in these diets.
Physicians fighting an uphill battle.
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Post by peppy on Dec 19, 2018 9:48:38 GMT -5
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Post by mnkdfann on Dec 19, 2018 11:16:07 GMT -5
Yes mnkdfann, but isn't it nice to know that going forward we will hear formally what we have been privy to anecdotally in regards to CGM use and Afrezza? If that's what you meant. I'm not sure what I said that confused you, what I meant is exactly what I said. That is (in response to what someone else wrote), there was in fact a lot about CGMs written in the SOC. Look for yourself. They are listed at least 24 times in the index (under several different headings, like continuous glucose monitoring, flash CGMs, JDRF CGM trials, etc.), and are discussed on at least 10 pages (especially around pages 81-88). I wasn't commenting on Afrezza at all (although I did subsequently ask a question concerning Afrezza of someone else).
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Post by longliner on Dec 19, 2018 11:36:26 GMT -5
Oh, no confusion, I'm crystal clear about your meaning.
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Post by peppy on Dec 19, 2018 11:38:00 GMT -5
Basal costs
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Post by peppy on Dec 19, 2018 11:47:27 GMT -5
The SGLT-2 are listed as benefit for the heart. Bone fractures and urinary track infections. Black Box warning amputation. GLP-1 black box warning Cancer.
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Post by mango on Dec 19, 2018 12:15:16 GMT -5
The SGLT-2 are listed as benefit for the heart. Bone fractures and urinary track infections. Black Box warning amputation. GLP-1 black box warning Cancer. SGLT-2s and GLP-1 both make Afrezza look like Charlie Brown. In fact it is the Charlie Brown. Who's foolin who? ADA foolin aint you. Who in their right mind can morally call those two things standards of care?
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Post by peppy on Dec 19, 2018 12:31:38 GMT -5
The median price for metformin is $2/month. Bottled water is more expensive. Did you leave your physicians office with a smile?
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Post by agedhippie on Dec 19, 2018 15:40:12 GMT -5
The SGLT-2 are listed as benefit for the heart. Bone fractures and urinary track infections. Black Box warning amputation. GLP-1 black box warning Cancer. Only only of the three SGLT2 drugs has the amputation risk, but they all give the CVD benefit which is why they are pushing SGLT2. Medically, being able to significantly reduce the risk of cardiovascular event as well as treat diabetes makes this drug an obvious choice as CVD is a major killer in Type 2. Interestingly that reduction only appears to work if you already have CVD. I think there is only a black box warning for Victoza and Bydureon, and that is theoretical (it exists in the rodent model but there is no evidence in humans). The other GLP-1 drugs don't have that a black box warning.
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Post by agedhippie on Dec 19, 2018 15:41:59 GMT -5
The median price for metformin is $2/month. Bottled water is more expensive. Did you leave your physicians office with a smile? Have you looked at table 9.3, comparative cost of insulin per 1000u? Definitely worth looking at.
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Post by peppy on Dec 19, 2018 15:42:06 GMT -5
The SGLT-2 are listed as benefit for the heart. Bone fractures and urinary track infections. Black Box warning amputation. GLP-1 black box warning Cancer. Only only of the three SGLT2 drugs has the amputation risk, but they all give the CVD benefit which is why they are pushing SGLT2. Medically, being able to significantly reduce the risk of cardiovascular event as well as treat diabetes makes this drug an obvious choice as CVD is a major killer in Type 2. Interestingly that reduction only appears to work if you already have CVD. I think there is only a black box warning for Victoza and Bydureon, and that is theoretical (it exists in the rodent model but there is no evidence in humans). The other GLP-1 drugs don't have that a black box warning. I saw that. under your observation only one of them causes amputation. I say go with that. Me, I am not falling for it. Buyer be ware.
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