Cutting down Metformin?

[RJN123]

Any thoughts or advice? I have been on 2x1000mg of metformin daily plus sitagliptin since July. I was also on gliclazide for a few months, but that was cut early on as my reading were steadying (Long story, but although T2, my diagnosis is likely linked to extended cancer treatment).

Over the past eight months, I have got back into shape, and readings are stable - and my TIR hover around the 90% mark whenever I buy a Libre. I have had HBA1C numbers of 39, 43 and 40 during this time (down from 80-something a year ago).

I have an appointment with the endocrinologist soon, and my sense is he will be pretty relaxed about cutting down my medication. Last time he encouraged me to drop one tablet and let me pick which one (I picked gliclazide). I am on a dozen medications for more serious/lifelong so am keen to reduce my diabetes medication. I have no side effects from any of them. I am inclined to reduce my metformin to 2x500 a day. The pills are massive and must be taken with food, so it would be nice to cut these down. Also, I feel that my blood sugar was more responsive to the sitagliptin, although as I started all within a few months, who knows?

I know this may not be the best reasoning, but I frankly haven’t gone into the scientific specifics too much given all my other medical issues which have taken up a lot of my research and energy, so I would really appreciate some thoughts from you well-researched folks. So in short, given the choice between dropping or cutting down sitagliptin (Januvia) or metformin, what should I be considering? Thank you in advance!

 

[Lucyr]

I’d keep the metformin and drop the sitagliptin personally, since the sitagliptin encourages your pancreas to produce more insulin

You mention being on lots of other medications. Don’t forget that unless you’re exempt from prescription charges for other reasons, you’ll need to start paying for your other medications if you stop all your diabetes medications.

 

[RJN123]

Thank you! Dumb question: why is producing more insulin bad?
I won’t lose my exemption as I have adrenal insufficiency after a bilateral adrenalectomy, so dependent on replacement steroids.

 

[Eddy Edson]

If I had to pick one, without knowing the details of yr situation etc etc etc, I guess I'd ditch the Januvia - just because it's a 2nd-line T2D med, whereas Metformin is 1st-line. But that doesn't mean I'd be right.

 

[Docb]

You seem to be doing what I would do....read around the subject and ask around to get yourself better informed but leave the decision making to the medics who have all the details with respect to all the things that are going on.

The point about being better informed is that you can get involved in the decision making and ask questions to be confident that all things have been taken into account.

 

[Lucyr]

Dumb question: why is producing more insulin bad?

If you work your pancreas too hard for too long it can get worn out. Metformin makes you use the insulin you have better, so that it needs less to do the job. Sitagliptin / Januvia makes you produce more insulin, because the insulin you produce isn’t effective enough.

 

[RJN123]

You seem to be doing what I would do....read around the subject and ask around to get yourself better informed but leave the decision making to the medics who have all the details with respect to all the things that are going on.

The point about being better informed is that you can get involved in the decision making and ask questions to be confident that all things have been taken into account.

Yes, for my cancer treatment and adrenal insufficiency I have been super involved and read every single medical paper and new studies and trials out there. It has allowed me to have very detailed conversations with my oncology team. But with diabetes I am relying more on others, including my DNS and endo. However, my endo isn’t all that bothered about my diabetes as my AI is the more serious condition, so I want to come prepared.

 

[RJN123]

If you work your pancreas too hard for too long it can get worn out. Metformin makes you use the insulin you have better, so that it needs less to do the job. Sitagliptin / Januvia makes you produce more insulin, because the insulin you produce isn’t effective enough.

Ah - very helpful. Thank you!

 

[Proud to be erratic]

Thank you! Dumb question: why is producing more insulin bad?

You might find this link, from the opening Welcome and Getting Started section of this Forum useful.

https://forum.diabetes.org.uk/boards/threads/what-is-type-2-diabetes.95406/

Many T2s routinely produce lots of insulin. But their body has a high natural resistance to insulin, preventing the transfer of glucose from their BG into the cells, muscles and organs that need the energy and general benefit of that glucose. Hence more insulin is not necessarily so helpful. Sometimes the pancreas eventually winds down on the insulin production and then medications that boost insulin production are needed - they can be oral or injected insulin. So which medication to drop is best not left to a guess!

T2 diabetes is a deceptively complex disease arising from a number of reasons and grouped collectively under a diagnosis of T2, which hides the nuances of the origins or changes that might occur with a progression of the disease. That complexity with potential major contradiction (eg produce lots or very little insulin) is unhelpfully promulgated by NICE and thus our first line HCPs. To the media its just one disease for all Types and potential breakthroughs for better treatments (or even full cures) are instantaneously available with the announcements.

Most diabetes diagnoses are hidden behind an anonymous title, eg Type 1, Type 2, Type 3c and as best I know only Gestational Diabetes gives a clue towards what is really at the root of the ailment.

I won’t lose my exemption as I have adrenal insufficiency after a bilateral adrenalectomy, so dependent on replacement steroids.

I wasn't aware that there were other medical reasons that attracted prescription charge exemptions; so thank you for a little bit more education. Always learning.

Often steroids cause raised BG and that can in itself become a form of diagnosis - and even sometimes referred to unofficially as steroid induced diabetes (actually one of the T3 sub-groups). Are you under your GP for your diabetes management or a Consultant? Was this a cause of your diabetes or even a consideration?

I see from a very brief look back at some of your earlier posts that your diabetes is relatively recent, you were successfully managing to keep your HbA1c in a good place and now less so. Do you know what brought about your original diabetes diagnosis and was that diagnosis made simply because your HbA1c was above the threshold - rather than what is causing it? Are you naturally very insulin resistant or under-producing insulin? If under producing have your D meds pushed your panc'y to work even harder and now exhausted your panc'y?

Apologies if my questions are intrusive; please don't answer if you'd rather not. You have a complex medical mix, as do I (but I'm less so). My Oncologist seemed very clear that only he was looking at all of my changing symptoms as potential markers for the return of cancerous cells; so far none. And my D is clear cut (no pun intended [?]) since I had a total pancreatectomy and know exactly what my non-existent panc'y can't do. Most members of this Forum have some constant uncertainty about their total pancreatic functions; even if they know their insulin production is zero there might be other unknown panc'y damage and reduced functionality.

 

[Proud to be erratic]

If you work your pancreas too hard for too long it can get worn out. Metformin makes you use the insulin you have better, so that it needs less to do the job. Sitagliptin / Januvia makes you produce more insulin, because the insulin you produce isn’t effective enough.

And thus which medication to drop is best not left to a guess!

 

[Proud to be erratic]

Yes, for my cancer treatment and adrenal insufficiency I have been super involved and read every single medical paper and new studies and trials out there. It has allowed me to have very detailed conversations with my oncology team. But with diabetes I am relying more on others, including my DNS and endo. However, my endo isn’t all that bothered about my diabetes as my AI is the more serious condition, so I want to come prepared.

That answers part of my questions earlier. My instinct is that even though the AI is the most important thing to look after I would not assume either a DSN or Endo is looking at the full picture. At least ask (I would send an email to the Endo's secretary for his attention) and get some reassurance that the full picture is being appraised.

 

[RJN123]

You might find this link, from the opening Welcome and Getting Started section of this Forum useful.

https://forum.diabetes.org.uk/boards/threads/what-is-type-2-diabetes.95406/

Many T2s routinely produce lots of insulin. But their body has a high natural resistance to insulin, preventing the transfer of glucose from their BG into the cells, muscles and organs that need the energy and general benefit of that glucose. Hence more insulin is not necessarily so helpful. Sometimes the pancreas eventually winds down on the insulin production and then medications that boost insulin production are needed - they can be oral or injected insulin. So which medication to drop is best not left to a guess!

T2 diabetes is a deceptively complex disease arising from a number of reasons and grouped collectively under a diagnosis of T2, which hides the nuances of the origins or changes that might occur with a progression of the disease. That complexity with potential major contradiction (eg produce lots or very little insulin) is unhelpfully promulgated by NICE and thus our first line HCPs. To the media its just one disease for all Types and potential breakthroughs for better treatments (or even full cures) are instantaneously available with the announcements.

Most diabetes diagnoses are hidden behind an anonymous title, eg Type 1, Type 2, Type 3c and as best I know only Gestational Diabetes gives a clue towards what is really at the root of the ailment.

I wasn't aware that there were other medical reasons that attracted prescription charge exemptions; so thank you for a little bit more education. Always learning.

Often steroids cause raised BG and that can in itself become a form of diagnosis - and even sometimes referred to unofficially as steroid induced diabetes (actually one of the T3 sub-groups). Are you under your GP for your diabetes management or a Consultant? Was this a cause of your diabetes or even a consideration?

I see from a very brief look back at some of your earlier posts that your diabetes is relatively recent, you were successfully managing to keep your HbA1c in a good place and now less so. Do you know what brought about your original diabetes diagnosis and was that diagnosis made simply because your HbA1c was above the threshold - rather than what is causing it? Are you naturally very insulin resistant or under-producing insulin? If under producing have your D meds pushed your panc'y to work even harder and now exhausted your panc'y?

Apologies if my questions are intrusive; please don't answer if you'd rather not. You have a complex medical mix, as do I (but I'm less so). My Oncologist seemed very clear that only he was looking at all of my changing symptoms as potential markers for the return of cancerous cells; so far none. And my D is clear cut (no pun intended [?]) since I had a total pancreatectomy and know exactly what my non-existent panc'y can't do. Most members of this Forum have some constant uncertainty about their total pancreatic functions; even if they know their insulin production is zero there might be other unknown panc'y damage and reduced functionality.

Not intrusive at all - we are here to share and find the best way forward for us all, however complex! Will try to answer your questions:

Re the exemptions, there are about a dozen exemptions, including both AI and cancer treatment (and as St 4 I will always be classed as such).
I was diagnosed before my surgery as my BG skyrocketed and my HBA1C was found to be 64 annd soon increased to 83. I and wasn’t on steroids, so not steroid-induced. However, my endocrinologist says he believes my cancer treatment (immunotherapy and radiotherapy) could well have brought it on, as I was never overweight or have any family history of diabetes. There is a lot we don’t know about immunotherapy, but I am in full remission from a stage 4 lung cancer diagnosis so not complaining!

I think that other than a slight increase due to travels and holidays, my diabetes is under control. I never have high readings outside mealtimes, and my TIR ranges from 90-95%.

Not sure about your question on insulin resistance - but will ask about this as I have no idea. I am being well looked after with a dedicated DNS at my GP and two check-ins a year with my endo. Plus if I have any issues, my oncology team are very helpful in getting me in to see specialists.

I have now done a bit of reading on sitagliptin, and it does seem it carries some risk, so I am grateful to be made aware of this. I do hate the massive metformin tablets, but obviously that is a minor consideration.

Thank you everyone for much-needed advice - I feel better prepared now!

 

[RJN123]

That answers part of my questions earlier. My instinct is that even though the AI is the most important thing to look after I would not assume either a DSN or Endo is looking at the full picture. At least ask (I would send an email to the Endo's secretary for his attention) and get some reassurance that the full picture is being appraised.

Oh yes, I know he is very much looking at the full picture. Apparently I am an “interesting” patient due to my complex medical history. My DNS has also read up on AI so she can factor that in.

 

[Proud to be erratic]

Oh yes, I know he is very much looking at the full picture. Apparently I am an “interesting” patient due to my complex medical history. My DNS has also read up on AI so she can factor that in.

Thank you for your 2 replies. I'm delighted to read you are in remission from your Stage 4 lung cancer and clearly you have good care teams around you.

 

[mark king]

Hello, here's my pennyworth.
Towards the end of last year my a nurse from my Drs practice rang me to say I was B12 deficient and that they wanted to confirm with another blood test. This repeat blood test showed I was marginally ok???
I had done some researching and found that Metformin can reduce B12 in diabetics so I stopped taking it. I did inform my diabetic nurse who said lets see what happens.
What has happened is that my B12 has improved.... a little but my diabetes is not quite as even as it previously was. My nurse wants to find out more after additional discussion with a doctor before adding it back in to my medication.
The Drs are aware of this down side with taking Metformin and there are some medical reports on the matter.

This is my story but it may not be fit for you however you could run it past your medical team if you get B12 issues.

take care.

Best

 

[JITR]

Looking at the whole picture is very sensible, and my gut feeling is have look at your diet before making decisions about medication. Maybe be a bit more research required,

If you do not know of Professor Taylor's Counterpoint study in c.2008 I'd suggest you have a look at all this Information for Doctors and this. Of course at BMI 23 your T2 may not be due to excess visceral fat but it could be. Waist to height and waist to hip ratios are tell tale signs.

In any case your blood glucose levels are largely a result of what you eat and how much of it. So adjustments maybe possible. For example is your diet in line with Dr David Unwin's diet sheet? You may have to watch this to put it in context.

One reason I chose diet over Metformin was no one seemed to know how it worked. Recent research has shown it acts on the mitochondria in a way which reduces the amount of food you digest (and a side effect is to reduce the number of mitochondra). One might think that adjust the types and amounts of food you eat would be a better bet. Have a look at Marty Kendall's optimising nutrition website for a data driven approach to selecting nutrient dense foods for satiety.

 

[RJN123]

Hello, here's my pennyworth.
Towards the end of last year my a nurse from my Drs practice rang me to say I was B12 deficient and that they wanted to confirm with another blood test. This repeat blood test showed I was marginally ok???
I had done some researching and found that Metformin can reduce B12 in diabetics so I stopped taking it. I did inform my diabetic nurse who said lets see what happens.
What has happened is that my B12 has improved.... a little but my diabetes is not quite as even as it previously was. My nurse wants to find out more after additional discussion with a doctor before adding it back in to my medication.
The Drs are aware of this down side with taking Metformin and there are some medical reports on the matter.

This is my story but it may not be fit for you however you could run it past your medical team if you get B12 issues.

take care.

Best

Thanks, but I don’t have any B12 issues.

 

[RJN123]

Looking at the whole picture is very sensible, and my gut feeling is have look at your diet before making decisions about medication. Maybe be a bit more research required,

If you do not know of Professor Taylor's Counterpoint study in c.2008 I'd suggest you have a look at all this Information for Doctors and this. Of course at BMI 23 your T2 may not be due to excess visceral fat but it could be. Waist to height and waist to hip ratios are tell tale signs.

In any case your blood glucose levels are largely a result of what you eat and how much of it. So adjustments maybe possible. For example is your diet in line with Dr David Unwin's diet sheet? You may have to watch this to put it in context.

One reason I chose diet over Metformin was no one seemed to know how it worked. Recent research has shown it acts on the mitochondria in a way which reduces the amount of food you digest (and a side effect is to reduce the number of mitochondra). One might think that adjust the types and amounts of food you eat would be a better bet. Have a look at Marty Kendall's optimising nutrition website for a data driven approach to selecting nutrient dense foods for satiety.

Sorry, I am confused - was this comment directed at me? My BMI is 21 and my question was re dropping medication as I am doing fine.

 

[harbottle]

If you work your pancreas too hard for too long it can get worn out.

Yet research doesn't show this is this case:

Effect of Exenatide, Sitagliptin, or Glimepiride on β-Cell Secretory Capacity in Early Type 2 Diabetes

Agents that augment GLP-1 effects enhance glucose-dependent β-cell insulin production and secretion and thus are hoped to prevent progressive impairment in insulin secretion characteristic of type 2 diabetes (T2D). The purpose of this study was ...

www.ncbi.nlm.nih.gov

After 6 months of treatment, exenatide or sitagliptin had no significant effect on functional β-cell mass as measured by β-cell secretory capacity, whereas glimepiride appeared to enhance β- and α-cell secretion.

Sitagliptin Increases Beta-Cell Function and Decreases Insulin Resista | DMSO

Sitagliptin Increases Beta-Cell Function and Decreases Insulin Resistance in Newly Diagnosed Vietnamese Patients with Type 2 Diabetes Mellitus

www.dovepress.com

Sitagliptin improved beta-cell function, insulin resistance and blood glucose in newly diagnosed patients with T2D. Meanwhile, Sitagliptin ameliorated serum GLP-1 concentrations, which contributed to the enhancement of beta-cell.

 

[Lucyr]

Yet research doesn't show this is this case

Experience shows it is, as T2s generally end up taking more and more medication over time