NICE Guidelines prevent a non medication solution to Diabetes Type 2

[Mountain Path]

The surgery knows the guidelines it seems.

If, as the op has said, their "annual review it showed a pretty good Hb1a that indicated that I could probably stop medication", how does that indicate the surgery is behaving incorrectly?
And where do the guidelines show it should be prescribed to counteract "a couple of beers or go to a restaurant"

Travellor, not withstanding your own diet and escaping from this situation (well done btw), that is exactly what these drugs are designed to do, they are designed to make sure people can live a moderately normal life consuming standard and bad food and taking drugs to allow them to do it.

So yes they are prescribed exactly to counteract "a couple of beers or goto a restaurant'.

Whether the guidelines explicitly state it or not that is the upshot of these medications.

You and I certainly know you can live without them if you eat well, granted maybe not everyone can medically and certainly few can from a will power perspective, but it is possible.

The debate was earlier whether you had to take them continuously to enable you to do this (which with Metformin seems to be the case) or they can be used as point effect drug, thus reducing drug use and side effects, cost and making people more responsible for their actions and overall health.

I offer no apologies for being a gourmet and enjoying food, beer and all the creativity in the world in these areas, nor am I a health puritan (apart from the ridiculous ingredients in some ready and takeaway food).

I am merely suggesting a better way, an intermediate way between ascetic dieting and continual drug use.

 

[Mountain Path]

Mea Culpa - looks like I misread the header post.

I won’t take my reply out or the thread won’t make sense.

@Apologies @Mountain Path . I read your post as your surgery not agreeing I you going for D&E.

Hi AndBreathe,

Your post is valuable and in fact I am still not sure they are following the guidelines for a different reason.

What they are currently having problems with is to assist my transition from drug dependency to Diet and Exercise. It seems that is all or nothing and this is a bit of a cliff edge as if I decide to give up drugs there is no easy way back (Considering the lag time for assessments).

This seems to contradict that 'tailoring treatment to the individual' as mentioned in the guidelines somewhere.

I wanted standby drugs in case of a failure (after all Christmas is coming and we may all be getting fat). This is apparently against the guidelines in their opinion.

That said they have arranged that a specialist diabetic clinician contact me to discuss options so maybe they will propose a spot effect drug, just not metformin.

I kinda regret telling them about the diet and exercise and probably should have put my low H1b reading down to taking the drugs then I could have just carried on but ordered the drugs much less often.

 

[everydayupsanddowns]

In addition the pinprick regime is very hard to maintain (if you want your fingers to work) and I know of no-one that manages to sample at a decent frequency using that method.

I checked with fingersticks around 8-10x a day for about a decade of my time on MDI - and I know there are others on the forum with similar BG checking habits - so it‘s perhaps not as rare as you think. (a big part of the national criteria for cost-neutral Libre prescription was the need to fingerstick 8x a day at one stage)

 

[AndBreathe]

Hi AndBreathe,

Your post is valuable and in fact I am still not sure they are following the guidelines for a different reason.

What they are currently having problems with is to assist my transition from drug dependency to Diet and Exercise. It seems that is all or nothing and this is a bit of a cliff edge as if I decide to give up drugs there is no easy way back (Considering the lag time for assessments).

This seems to contradict that 'tailoring treatment to the individual' as mentioned in the guidelines somewhere.

I wanted standby drugs in case of a failure (after all Christmas is coming and we may all be getting fat). This is apparently against the guidelines in their opinion.

That said they have arranged that a specialist diabetic clinician contact me to discuss options so maybe they will propose a spot effect drug, just not metformin.

I kinda regret telling them about the diet and exercise and probably should have put my low H1b reading down to taking the drugs then I could have just carried on but ordered the drugs much less often.

The thing with "standby drugs" is their APPROPRIATE use, or not.

As others have said, Metformin will only help, and then only a little, when a therapeutic dose is reached, which takes time longer than a few hours or a day. Gliclazide, on the other hand, is a fairly quick acting medication, which can cause hypos, depending on the circumstances. Bearing in mind the stories we are hearing of long waits for medical help, I wouldn't want to be risking worrying hypos any time soon.

I am fortunate that sweet things don't float my boat. I can pass them by all day and all night long, day on day out, then add in my requirement to be gluten free, foods containing grains have just been binned. I haven't eaten break, biscuits or cakes for about 8 years. Obviously, that isn't for everyone.

My preference for savoury foods leads me to meats, cheese and so on, although I can be tempted by Kettle Chips. When the planets align, I swear I could manage my body weight in those delicious morsels.

In terms of the all or nothing approach; have you tried negotiating? In your shoes, I would try negotiating for ditching Gliclazide, but retaining Metformin, which can have benefits beyond diabetes for some, and a repeat A1c test in 3 months. If you have concerns about the festive season, you could try negotiating the new regime starting January.

It's up to you how you proceed, but when it comes to the prescription pad, your medics are in ultimate control, so if you are looking to go off plan, discussion is the way forward.

 

[Mountain Path]

I checked with fingersticks around 8-10x a day for about a decade of my time on MDI - and I know there are others on the forum with similar BG checking habits - so it‘s perhaps not as rare as you think. (a big part of the national criteria for cost-neutral Libre prescription was the need to fingerstick 8x a day at one stage)

In one of my 'focused phases' i was also testing many times a day, not sure if it was as many as 8-10, but after a few days my fingers got sore and i found it difficult typing (I work in IT) tried several solutions (locations and 4 different lancing methods) but could never keep the frequency up for more then a week or so without creating painful temporarily unusable fingertips. (maybe i was doing something wrong?)

This is why I looked into continuous monitoring devices (backed up still by fingerpricks) so far they have been very good (tried two types so far) my current one takes about 12 readings an hour and automatically uploads it to my phone (and from there to other apps).

As well as stats it has alarms and thus i never have an excuse to allow high or low readings for more then 20-30 minutes, providing i have an effective response protocol.

It also allows me to see the real time effect of what I eat, do and even feel (stress does on crease my glucose levels).

This is why I think this method is the way forward on so many fronts and should be the main focus in NICE (as well as effective rapid mitigation drugs and actions).

On the whole i think the future on many fronts is auto monitoring devices for a range of health conditions. Long period testing or only seeking assistance as a responsive action to obvious symptoms really is insufficient and overall more expensive

 

[everydayupsanddowns]

The best lancing devices I found were the Accu-Chek …clix ones (Soft clix, multi clix, fast clix etc)

They seem to be able to produce a reliable sample with very low penetration. And the lancets are good for a lot of uses before I need to swap to the next in the drum. (every St Swithin’s Day, whether I need to or not 😉)

I was always told to use the sides of fingertips rather than pads (fewer nerve endings) and can use both sides with a bit of contortion. They are a bit calloused and tough after my 30+ years of finger jabbing, but my frequency of fingersticks has dropped dramatically since moving to sensors, especially Dexcom.

NICE recently recommended sensors for certain T2s which was a first. And and update to T1 guidance has broadened the recommendations there too. As costs come down, and more data that emerge I think this will certainly be the direction of travel.

Recommendations | Type 2 diabetes in adults: management | Guidance | NICE

www.nice.org.uk

(scroll down to CGM section)

 

[Mountain Path]

The thing with "standby drugs" is their APPROPRIATE use, or not.

As others have said, Metformin will only help, and then only a little, when a therapeutic dose is reached, which takes time longer than a few hours or a day. Gliclazide, on the other hand, is a fairly quick acting medication, which can cause hypos, depending on the circumstances. Bearing in mind the stories we are hearing of long waits for medical help, I wouldn't want to be risking worrying hypos any time soon.

I am fortunate that sweet things don't float my boat. I can pass them by all day and all night long, day on day out, then add in my requirement to be gluten free, foods containing grains have just been binned. I haven't eaten break, biscuits or cakes for about 8 years. Obviously, that isn't for everyone.

My preference for savoury foods leads me to meats, cheese and so on, although I can be tempted by Kettle Chips. When the planets align, I swear I could manage my body weight in those delicious morsels.

In terms of the all or nothing approach; have you tried negotiating? In your shoes, I would try negotiating for ditching Gliclazide, but retaining Metformin, which can have benefits beyond diabetes for some, and a repeat A1c test in 3 months. If you have concerns about the festive season, you could try negotiating the new regime starting January.

It's up to you how you proceed, but when it comes to the prescription pad, your medics are in ultimate control, so if you are looking to go off plan, discussion is the way forward.

Yup my diet is similar to yours and I avoid sweet things as well.

I plan to negotiate and find alternative drugs myself and suggest them. It looks like only insulin is a sure mitigation drug as it is used in emergency situations although glucozide is a contender.

In regard to hypos I never have trouble stopping those (if not occurring while asleep) a quick intake of sugar (normally a sweet) counters low blood sugar alerts within minutes, its the highs that are the problem as exercise my only sure solution at the moment and that is not always possible.

 

[AndBreathe]

Yup my diet is similar to yours and I avoid sweet things as well.

I plan to negotiate and find alternative drugs myself and suggest them. It looks like only insulin is a sure mitigation drug as it is used in emergency situations although glucozide is a contender.

In regard to hypos I never have trouble stopping those (if not occurring while asleep) a quick intake of sugar (normally a sweet) counters low blood sugar alerts within minutes, its the highs that are the problem as exercise my only sure solution at the moment and that is not always possible.

I doubt insulin would ever be made available to you in your current state of health.

Vis-a-vis hypos, medics are usually a significantly more concerned about hypos, which can be damaging or even fatal very quickly, whereas harm from high blood sugars tends to be a much slower process. This is the rationale behind medics/nursing staff in hospitals being content with higher blood sugars that folks would like at home.

If your concerns are genuinely around high days and holidays, then my advice would be to cut yourself some slack. I'm sure you can undo a couple of days indulgence promptly. If, however, you have concerns that relaxing a bit would lead to a few more days leading to a few weeks or months of indulgence, then that is a totally different issue. Only you can know your potential.

 

[Deleted member 21371]

LOL, yup although a side effect of exercising is also getting fit.

That said if the drug does effectively block sugar you would not increase your weight as a result of the sugar and carbs probably, (People taking it as a diet drug risk?)

That said my current diet has no sugar and virtually no carbs, but I compensate with Proteins and fats, a plate of regional cheeses and a pound of raspberries with a pint of double cream will soon negate any weight loss plans but have virtually no effect on glucose levels. My apps tell me that if I want to continue my route to an ideal BMI its more then just cutting out sugars and carbs, not to mention cholesterol levels that since my diet change has been elevated for the first time ever, there is always something.

It you have a drug that can block sugar, again, you probably have the holy grail for the diet industry.

And if you are asking the NHS to endorse an extreme keto diet as your treatment, they won't.

 

[Deleted member 21371]

Travellor, not withstanding your own diet and escaping from this situation (well done btw), that is exactly what these drugs are designed to do, they are designed to make sure people can live a moderately normal life consuming standard and bad food and taking drugs to allow them to do it.

So yes they are prescribed exactly to counteract "a couple of beers or goto a restaurant'.

Whether the guidelines explicitly state it or not that is the upshot of these medications.

You and I certainly know you can live without them if you eat well, granted maybe not everyone can medically and certainly few can from a will power perspective, but it is possible.

The debate was earlier whether you had to take them continuously to enable you to do this (which with Metformin seems to be the case) or they can be used as point effect drug, thus reducing drug use and side effects, cost and making people more responsible for their actions and overall health.

I offer no apologies for being a gourmet and enjoying food, beer and all the creativity in the world in these areas, nor am I a health puritan (apart from the ridiculous ingredients in some ready and takeaway food).

I am merely suggesting a better way, an intermediate way between ascetic dieting and continual drug use.

An example of tonight's meal out, (along with the wine and beer).
Yesterday's lunch was a simple Steak and Stilton pie and mash at the farm shop.
I can't really say I'm a puritan, I don't think anybody are on here.

 

[harbottle]

Travellor, not withstanding your own diet and escaping from this situation (well done btw), that is exactly what these drugs are designed to do, they are designed to make sure people can live a moderately normal life consuming standard and bad food and taking drugs to allow them to do it.

So yes they are prescribed exactly to counteract "a couple of beers or goto a restaurant'.

Not Metformin. It has limited effects and doesn't work directly on blood sugar in the same way sulfonylurea does, which can be used in response to a meal to keep levels down.

I know someone who is on Met, Glic and one that makes the kidneys remove sugar - and still has to keep to a restricted diet to keep hba1c in safe levels.

 

[42istheanswer]

Hi AndBreathe,

Your post is valuable and in fact I am still not sure they are following the guidelines for a different reason.

What they are currently having problems with is to assist my transition from drug dependency to Diet and Exercise. It seems that is all or nothing and this is a bit of a cliff edge as if I decide to give up drugs there is no easy way back (Considering the lag time for assessments).

This seems to contradict that 'tailoring treatment to the individual' as mentioned in the guidelines somewhere.

I wanted standby drugs in case of a failure (after all Christmas is coming and we may all be getting fat). This is apparently against the guidelines in their opinion.

That said they have arranged that a specialist diabetic clinician contact me to discuss options so maybe they will propose a spot effect drug, just not metformin.

I kinda regret telling them about the diet and exercise and probably should have put my low H1b reading down to taking the drugs then I could have just carried on but ordered the drugs much less often.

My understanding of "tailor to the individual" in the NICE guidance is that they don't, for instance, have to follow the general guidance of metformin as the first medication offered if the individual has a reason why it may not be suitable (e.g. other medical conditions or other medication). My practice nurse was willing to offer me a couple of alternatives as a first line medication as I have IBS, so the gastrointestinal side effects from metformin would be likely to be exacerbated.

I preferred to try diet first and have my fingerprick blood glucose readings suggesting my dietary changes have been enough so far.

I don't see anything in the NICE guidance which suggests that intermittent use of medication would be recommended. I would have thought that if your diet is usually low carb enough that your blood sugars are under control that occasionally having one donut, or a meal out that includes more carbs, wouldn't have the effect of significantly impacting your overall blood glucose management. After all even non-diabetics will occasionally have a high peak. If you are eating those higher type of carb foods often enough that it is having a significant impact, I would suggest that actually your overall diet isn't low carb.

I would also note that GPs can track how frequently medication is requested, so unless you were deliberately wasting NHS money by ordering medication you weren't then taking, they would notice if you were telling them that you were taking medication regularly but actually only taking (and requesting repeats) intermittently.

 

[Deleted member 21371]

What is the range you keep your BG in?

 

[helli]

In one of my 'focused phases' i was also testing many times a day, not sure if it was as many as 8-10, but after a few days my fingers got sore and i found it difficult typing (I work in IT) tried several solutions (locations and 4 different lancing methods) but could never keep the frequency up for more then a week or so without creating painful temporarily unusable fingertips. (maybe i was doing something wrong?)

CGMs are great but those of you us who have had Type 1 for decades have been used to finger pricking 8 to 10 times a day. And still be able to type at a computer with no problems.
I had a regime for finger selection and used all fingers every other day.
I appreciate some people are more sensitive but the media's obsession with "painful finger pricks" that CGM manufacturers jump onto is unnecessarily misleading

 

[Bruce Stephens]

I appreciate some people are more sensitive but the media's obsession with "painful finger pricks" that CGM manufacturers jump onto is unnecessarily misleading

Yes, for most of us that's really not what CGMs are for.