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Post by sayhey24 on Feb 2, 2017 20:29:52 GMT -5
Explaining to T2 coworkers of the benefits of Afrezza versus metformin is relatively easy, however, because our insurance currently does not cover Afrezza it is difficult for them to make the switch. Are there papers that spell out compelling reasons to switch? As a starting point the statistics are that less than 40 percent of patients with diabetes successfully achieve an A1C level of less than 7 percent. Thats including those using metformin. Thats an average BG of 154mg/dl. Microvascular damage begins at prolonged levels above 140. I have developed a protocol which seems to be working very well with the T2 coworker crowd. Bottom line is you need to baseline what their current BG is doing. T2s have decreased insulin secretion or increased hepatic glucose output or both. As the BG rises they will also have insulin resistance. If the PWD is not producing enough insulin, taking metformin to decrease liver sugar output is not addressing the problem. The following is in general terms. If your friend goes to bed at 95 and wakes up at 120 metformin maybe a better choice than afrezza to suppress the night time sugar. Then again a shot or two of whiskey may have the same effect. If before eating their BG is 95 and after their BG is shooting 150+ they have a phase 1 insulin release issue. If after 2 hours its still 140+ they probably have a phase 2 issue. A non diabetic should be back to 85 after 2 hours. For phase 1 and 2 issues, metformin can not address this issue and thats where afrezza can help. I have had my T2 coworker crowd get the Abbott Libre as you will need at least 10 measurements per day to baseline and track. The magic number is <100mg/dl during fasting which is very doable with afrezza. Above that the pancreas is still going to be in phase 2 release. Get them below 100 during fasting and keep them there for 3 months and I bet you will see why there are so many papers on early insulin use in T2s. After the 3 months there is a pretty good chance a low carb diet and exercise will do it with a shot of whiskey before bed once in awhile.
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Post by Deleted on Feb 3, 2017 5:16:00 GMT -5
sayhey24 interesting you mentioned hepatic glucose output. From what I recall my coworker's BG rises overnight while on metformin, so apparently there is more to it?
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Post by sayhey24 on Feb 3, 2017 6:34:28 GMT -5
sayhey24 interesting you mentioned hepatic glucose output. From what I recall my coworker's BG rises overnight while on metformin, so apparently there is more to it than hepatic glucose output. Kastanes - all T2s are not the same. If you put 12 T2s in a room you may get 12 different root causes for their diabetes and its usually not one issue so they may share issues to different degrees. One thing they will all have in common is they all have too much sugar in their blood. The primary action of metformin is to reduce the liver from putting sugar in the blood. So, at a 30k foot level; metformin is not having the proper reaction with the liver, or your friend is under dosing or your friend is really under producing insulin or their resistance to insulin is high or some combination. Then again they may have another medical issue. Now the problem today is their doctor is probably just going to say - walk a little and take these pills and you will be fine. And I bet the doctor has no BG profile for your friend.
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Post by Deleted on Feb 3, 2017 6:40:05 GMT -5
sayhey24 actually my coworker has quite a bit of blood-work because his kidneys are indicating signs of damage and his doctor reduced his metformin from twice a day to once a day. So obviously, metformin is not managing his diabetes well.
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Post by peppy on Feb 3, 2017 7:30:02 GMT -5
sayhey24 actually my coworker has quite a bit of blood-work because his kidneys are indicating signs of damage and his doctor reduced his metformin from twice a day to once a day. So obviously, metformin is not managing his diabetes well. That is the ticket. The physician is on it as the table says to lower the dose. Those steps now accomplished, step done, another therapy may be able to be obtained.
packageinserts.bms.com/pi/pi_glucophage_xr.pdf
Renal Insufficiency In patients with decreased renal function (based on measured creatinine clearance), the plasma and blood half-life of metformin is prolonged and the renal clearance is decreased in proportion to the decrease in creatinine clearance (see Table 1; also see WARNINGS).
Metabolism and Elimination Intravenous single-dose studies in normal subjects demonstrate that metformin is excreted unchanged in the urine and does not undergo hepatic metabolism
(My words, metformin taking out his kidneys)
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Post by Deleted on Feb 3, 2017 7:44:29 GMT -5
Metformin gave false assurance that his diabetes was 'well managed' because his numbers were 'good enough'. Unfortunately, his kidneys are indicating his diabetes is NOT 'well managed' despite his doctor's acceptance.
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Post by agedhippie on Feb 3, 2017 8:50:30 GMT -5
Metformin gave false assurance that his diabetes was 'well managed' because his numbers were 'good enough'. Unfortunately, his kidneys are indicating his diabetes is NOT 'well managed' despite his doctor's acceptance. Does he have high blood pressure? That has a strongly amplifying effect kidney damage (think sand blasting). If his numbers are good his blood pressure may well be causing more issues than his levels. I am curious that they have him on metformin twice a day, it's normally dosed once a day. That is done sometimes to get over the initial symptoms but he should have been moved to a single dose after a couple of months. There is no harm in dosing twice a day, it's just easier to only dose once. The rise in the early hours of the morning is known as dawn phenomena. Your liver glucose output varies throughout the day with a low point around 2 - 3 am after which it rises steadily peaking around 5 -6 am. The idea is to conserve energy when it isn't needed and to have it available when you wake. A pump is the only way to handle that because the basal can vary from hour to hour. Otherwise you just correct as part of your breakfast bolus and live with the earlier spike.
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Post by Deleted on Feb 3, 2017 8:59:46 GMT -5
agedhippie he does not have high blood pressure; he works out regularly, is thin and eats well. He was taking metformin twice daily for years, but recently reduced to once a day. A second T2 coworker is taking metformin twice a day and he is showing symptoms of eye deterioration. He asked his doctor if Afrezza is right for him and her reply was 'your numbers are good enough'! I have convinced him that he has to demand it or change doctors.
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Post by sportsrancho on Feb 3, 2017 10:16:28 GMT -5
agedhippie he does not have high blood pressure; he works out regularly, is thin and eats well. He was taking metformin twice daily for years, but recently reduced to once a day. A second T2 coworker is taking metformin twice a day and he is showing symptoms of eye deterioration. He asked his doctor if Afrezza is right for him and her reply was 'your numbers are good enough'! I have convinced him that he has to demand it or change doctors. Good work! Everyone on this board should get out there and start talking! And don't say anything about not being pushy. Get a Dreamboat, put it in your pocket. And tell at least one person a day!!
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Post by agedhippie on Feb 3, 2017 10:20:41 GMT -5
agedhippie he does not have high blood pressure; he works out regularly, is thin and eats well. He was taking metformin twice daily for years, but recently reduced to once a day. A second T2 coworker is taking metformin twice a day and he is showing symptoms of eye deterioration. He asked his doctor if Afrezza is right for him and her reply was 'your numbers are good enough'! I have convinced him that he has to demand it or change doctors. So he is a lean Type 2 then yes, Afrezza is definitely a good choice for him. He should probably keep taking metformin because that will manage his basal output and ensure that his insulin resistance doesn't rise but other than that I agree with you and insulin is a good choice at this point. For the second co-worker what eye deterioration is he seeing? Are there bleeds?
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Post by Deleted on Feb 3, 2017 10:28:28 GMT -5
agedhippie unfortunately he is not on the ball and just accepts whatever his doctor tells him; in other words he doesn't know any details of his eyes.
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Post by sayhey24 on Feb 3, 2017 20:05:55 GMT -5
Metformin gave false assurance that his diabetes was 'well managed' because his numbers were 'good enough'. Unfortunately, his kidneys are indicating his diabetes is NOT 'well managed' despite his doctor's acceptance. Kastances - it seems your two friends are classic T2s. The only thing which is going to lower BG the way their pancreas would if they were healthy is with insulin identical to what the pancreas secretes. There is only one medication which is this exact same monomer insulin and its afrezza. No analog is going to do it like the pancreas and your two friends are now living the down side of metformin treatment. Even worse they are living through the classic metformin false assurance. I am not giving you medical advice but if I was one of your friends I would have to make a decision pretty soon; either decide to make a change or continue down this recursive health plunge. If it were me I would choose the former and if so based on what you have said I would first baseline my BG during the day. This will require 10 measurements (before meal, 1 hour after meal and 2 hrs after meal and before bed) per day for at least 2 weeks along with a log of what I ate plus the times and amount of metofrmin taken. I would then take 2 days off the metformin and eat the exact same as 2 prior days. I would then find a doctor who understands this BG profile which they are being shown and leave that day with the script for the titration pack and a pocket full of samples. Once I had the afrezza in my hands I would throw the metformin in the trash. Once on afrezza I would continue the 10 measurements until I saw the trends and make sure I was second dosing when needed after meals to mimic 2nd phase pancreatic insulin release - this second dosing is key and they may even require a 3rd dose 90 minutes after 2nd dose. Doing all the measurements with my current BG meter is hard so I would get the Abbott Libre and the scanner. The scanner runs about $100 on ebay. With all these measurements it will also be cheaper than using all those strips as the sensor lasts about 2 weeks. I will be surprised if in 3 months, assuming a low carb diet and exercise I can't get my fasting BG under 100. If so I should have a pretty good chance the beta cells will start to regenerate, my liver will reset and my insulin sensitivity will increase. If not I probably waited too long or I have other issues. Also, you have heard about the "soft" hypos people are seeing with afrezza vs the typical hypo. This is because below 80 the liver will kick in and raise the BG and because afrezza is out of the blood so fast, the liver can do the job unlike with the Analogs which take the BG lower.
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Post by Deleted on Feb 3, 2017 23:24:27 GMT -5
Spoke with the coworker going to his doctor Monday: at last check his a1c was 6.1 and fasting BG 220! This shows how misleading an average, such as a1c, could be.
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Post by agedhippie on Feb 4, 2017 12:55:21 GMT -5
Spoke with the coworker going to his doctor Monday: at last check his a1c was 6.1 and fasting BG 220! This shows how misleading an average, such as a1c, could be. Something is wrong there. If his fasting levels are 220 and his A1c is 6.1 then they need to dig deeper as to why his A1c is so far out. If I was him I would be insisting strongly that the doctor explains how he reconciles these two numbers. There are various disorders that can cause that and if I was him I would want that fixed. The other possibility is that they use one of those little in-office kits which are very sensitive to operator error, I would want it done on a proper lab array, in New York Quest Diagnostics have a good array. He sounds like a prime candidate for a couple of weeks with a CGM to get a better view of what is happening.
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Post by hopingandwilling on Feb 4, 2017 13:26:11 GMT -5
sayhey24 interesting you mentioned hepatic glucose output. From what I recall my coworker's BG rises overnight while on metformin, so apparently there is more to it than hepatic glucose output. Kastanes - all T2s are not the same. If you put 12 T2s in a room you may get 12 different root causes for their diabetes and its usually not one issue so they may share issues to different degrees. One thing they will all have in common is they all have too much sugar in their blood. The primary action of metformin is to reduce the liver from putting sugar in the blood. So, at a 30k foot level; metformin is not having the proper reaction with the liver, or your friend is under dosing or your friend is really under producing insulin or their resistance to insulin is high or some combination. Then again they may have another medical issue. Now the problem today is their doctor is probably just going to say - walk a little and take these pills and you will be fine. And I bet the doctor has no BG profile for your friend.
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