Apologies This is a long one. I'll make it brief as possible, but think the history is important too.
I've been with Chris for 19 years, but way before I knew him, in 1991 at 34 he suffered a heart attack. Now, he had just completed a cycle ride from John O'Groats to Lands End for Gingerbread, the lone parents organisation. He'd had a medical 2 days before. The heart attack happened two days after he completed the fundraiser. In hospital T2 diabetes was given as the cause, suffering nerve damage over a long period of time. He'd never noticed symptoms, had no idea he was diabetic, and it didn't show on his medical before the bike-ride.
Two years later he suffered another, overdoing it, he was digging out a pond at the time. he survived that too.
We met in 2001, he said he was 'fighting' the diabetes, but the reality was he was in denial, and just carrying on. He refused to test himself or let me do it, only has once-a-year reviews and is horribly needle-phobic. He was on 5 Metformin a day, 4 Gliclazide a day and 2 glucobay per day
2003 he suffered a TIA, close to his optic nerve so he lost a small percentage of left side peripheral vision, and lost some hand to eye co-ordination for a few months. Many dropped cups, cutlery laid the wrong way round etc, when he couldn't judge distance between object and tabletop. He made pretty much a full recovery from this, only showing small signs when tired.
2011 they attempted a second peripheral angioplasty for the arterial blockages in his legs, the first, 5 years earlier had been completely unsuccessful and was abandoned. This caused infection almost immediately, and gangrene flared in his left foot. It took me three weeks to convince the GPs that this is NOT something you would expect to see. By then it was too late and he lost his foot. As he was in hypo (1.6) when he went in, they took him off Glucobay and Gliclazide, and reduced his metformin to 4 a day. He forgot several times that the foot was no longer there and fell on the stump, which resulted in infection and removal of the knee. Once the knee was removed, and due to some slight balance issues following the stroke on some days, his crutches and frame were removed, leaving him unable to use the bathroom whilst we waited for adaptations, which took a year to put into place. So he had to use a commode in the bedroom.
During this time he allowed me to test him twice a day, morning and night, for a few months. I kept a food diary, noting what seemed to cause spikes etc. After a review he was put back on 2 gliclazide per day. He also had nightly diarrhoea.
We had mentioned this to GPs and anyone we spoke to about his diabetes. It was dismissed every single time as 'probably the Metformin' but when you are the one who has to empty that commode out many times each night, from about 9pm and sometimes until 3am every night without a break (and I was working at the time), you know something is wrong. Tears, arguing, reasoning, didn't convince anyone it wasn't just metformin. Mentioning it every time didn't convince them that perhaps they need to run a few tests. So in the end I took matters into my own hands, and stared eliminating some foods. Dairy was the first to go as I had noticed if he had cheese, even a small amount, he'd have a big spike and it would take a couple of days to come back down to an acceptable level. He did like his milk, and we were getting through four pints a day. Well it was instant. No Diarrhoea, it just stopped. Gave him a milky coffee three weeks later....won't be doing that again! So he's lactose intolerant. Bingo!
I have to tell GPs and hospitals this every single time, they don't seem to want to put it on their records. Even his diabetic nurse is surprised every time we tell her, which is every time we see her.
Anyway, since that discovery, his diabetes has been under good control, with removal of lactose from his diet being the only change we made, and though his other foot is in a none-too-healthy state, it hasn't got worse in all that time, in fact a slight improvement over several years is noted, in that they can pick up a pulse where they couldn't without a Doppler before.
Right, so there is his blood pressure. Already on Atenolol since the heart attack, put on Perindropril after the stroke, along with Atorvastatin and Bezafibrate and Clopidogrel (Plavix). When first put on Peridopril, it was controlled as always, starting on 2mg, then 4mg then 8mg, but he felt ill after 8mg so the doctor reduced the dose to 6mg after low BP reading, and suggested 6mg was his limit of tolerance.
Last year he showed a small excess of protein in his urine. so he was referred to the renal doctor, and given an ultrasound scan. There we discovered he only has one kidney, 15% larger but still only one. However the renal doctor discharged him in that it was only slight and the diabetes was clearly in good control, to be monitored annually. GP raised his Perindopril to 8mg in spite of my protests saying there is a reason he was on 6 and not 8 for all these years. But it's an Ace Inhibitor, this is for his kidney now.
His BP rose, almost immediately. I have to add it had been normal for all the years he was on 6mg. I suggested that research shows a very few patients do have this and again, he is now above his tolerance. (levels of blood enzyme Renin causes the reverse effect in between 7% and 16% of patients) They disagreed. In fact, they put him on 10mg. Needless to say this also had no effect on his BP, so they raised his Atenolol to 75mg daily. No effect. In June this year, he was put on Lansoprazole as Ranitidine was no longer available. He's also on aspirin so this is something he has been taking since the heart attack I think. In July, Atenolol was raised to 100mg daily, and whilst still on Perindopril 10mg which clearly wasn't working he had Amlodipine 5mg added to the mix. Within a week of taking Amlodipine he suffered diarrhoea which got worse over the next three weeks until it became so explosive he lost all bowel control. He refused to take any more Amlodipine, his BP was still high anyway, and we called the GP who agreed. However a week later it was as bad as ever, removing Amlodipine had no effect. Samples were taken both general and a 'Fit' test. infection was ruled out and there was no blood or signs that it could be something nastier. GP came on a home visit to perform rectal and abdominal examination, no lumps or constipation blockage found. By this time I knew his glucose levels were dropping, he was confused and slurred. However his refusal to test meant I had no lancets and strips so I had to work with what I had. He refused to eat, though was drinking 4-5 pints of water a day, but did try a couple of biscuits and a sweet drink, I also put a half tsp sugar in his coffee over a period of an hour, to raise it slower, and it seemed fine, he was ok. He chose to have a slice of toast with a thin spread of jam on, (up till then he had only eaten dry toast). GP prescribed immodium and told me to stop his Gliclazide. I went to the chemist next day to get it, making sure he was ok for the hour it was going to take. He was fine as I left. When I got back he was unconscious. I had to revive him with sugar and a sweet drink, but as often happens, a spike and then a crash a couple of hours later. Then he revived again, then vomited, then passed out over the loo. I called the ambulance, paramedics put him on a drip and it took 2 hours to get his levels up to 5.0. They took him in,. where it was found he was suffering stage 2 Acute Kidney Injury due to dehydration. They took him off ALL medication only re-introducing most of them on discharge.
So he was discharged from hospital, and kept OFF Gliclazide and Metformin and Perindopril. To be reviewed in two weeks, and if needed to be put back on Metformin, but if the diarrhoea starts again, they should try a gliptin.
However it's now three weeks since discharge, and we have not been able to give him any diabetes meds, even though his readings are average 13.5 daily. I'm testing three times a day, no major spikes, but it varies between 9.5 and 16. GP said as long as it doesn't go more wildly than that he can sustain it for a while longer until we get the diarrhoea stopped. Suggested perhaps taking him off Lansoprazole to see if that makes a difference.
Voila! 36 hours later, no more diarrhoea, no more lack of bowel control. 48 hours and we have two dry nights.
We have a consultation with gastro-enterology, who are leaning toward Inflammatory Bowel Disease, I'm leaning toward a microscopic colitis, possibly collagenous colitis and Lansoprazole seems to be top of the list of irritant medications in that.
So here's my question. I'm not keen on him going back to metformin if a gliptin is a viable alternative, as suggested by the hospital, which one can I push for? I'm hearing good things about it, and perhaps this is what he needs to continue with better control of his T2. But while the GPs are finally in a mood to actually listen I'd like to discuss it as a possibility. Chris doesn't particularly want to go back on Metformin, and is adamant that Perindopril is not going anywhere near his mouth, that frightened him badly. I've said he might have to for his kidney, but no more than 6mg. and the GP agreed it would only be reintroduced in a very controlled manner.
So what type of Gliptin has shown good results? Is it a viable alternative to using Metformin? Does anyone use Gliptins instead of Metformin or alongside it? Give me a name I can suggest at our next consultation. please.
I've been with Chris for 19 years, but way before I knew him, in 1991 at 34 he suffered a heart attack. Now, he had just completed a cycle ride from John O'Groats to Lands End for Gingerbread, the lone parents organisation. He'd had a medical 2 days before. The heart attack happened two days after he completed the fundraiser. In hospital T2 diabetes was given as the cause, suffering nerve damage over a long period of time. He'd never noticed symptoms, had no idea he was diabetic, and it didn't show on his medical before the bike-ride.
Two years later he suffered another, overdoing it, he was digging out a pond at the time. he survived that too.
We met in 2001, he said he was 'fighting' the diabetes, but the reality was he was in denial, and just carrying on. He refused to test himself or let me do it, only has once-a-year reviews and is horribly needle-phobic. He was on 5 Metformin a day, 4 Gliclazide a day and 2 glucobay per day
2003 he suffered a TIA, close to his optic nerve so he lost a small percentage of left side peripheral vision, and lost some hand to eye co-ordination for a few months. Many dropped cups, cutlery laid the wrong way round etc, when he couldn't judge distance between object and tabletop. He made pretty much a full recovery from this, only showing small signs when tired.
2011 they attempted a second peripheral angioplasty for the arterial blockages in his legs, the first, 5 years earlier had been completely unsuccessful and was abandoned. This caused infection almost immediately, and gangrene flared in his left foot. It took me three weeks to convince the GPs that this is NOT something you would expect to see. By then it was too late and he lost his foot. As he was in hypo (1.6) when he went in, they took him off Glucobay and Gliclazide, and reduced his metformin to 4 a day. He forgot several times that the foot was no longer there and fell on the stump, which resulted in infection and removal of the knee. Once the knee was removed, and due to some slight balance issues following the stroke on some days, his crutches and frame were removed, leaving him unable to use the bathroom whilst we waited for adaptations, which took a year to put into place. So he had to use a commode in the bedroom.
During this time he allowed me to test him twice a day, morning and night, for a few months. I kept a food diary, noting what seemed to cause spikes etc. After a review he was put back on 2 gliclazide per day. He also had nightly diarrhoea.
We had mentioned this to GPs and anyone we spoke to about his diabetes. It was dismissed every single time as 'probably the Metformin' but when you are the one who has to empty that commode out many times each night, from about 9pm and sometimes until 3am every night without a break (and I was working at the time), you know something is wrong. Tears, arguing, reasoning, didn't convince anyone it wasn't just metformin. Mentioning it every time didn't convince them that perhaps they need to run a few tests. So in the end I took matters into my own hands, and stared eliminating some foods. Dairy was the first to go as I had noticed if he had cheese, even a small amount, he'd have a big spike and it would take a couple of days to come back down to an acceptable level. He did like his milk, and we were getting through four pints a day. Well it was instant. No Diarrhoea, it just stopped. Gave him a milky coffee three weeks later....won't be doing that again! So he's lactose intolerant. Bingo!
I have to tell GPs and hospitals this every single time, they don't seem to want to put it on their records. Even his diabetic nurse is surprised every time we tell her, which is every time we see her.
Anyway, since that discovery, his diabetes has been under good control, with removal of lactose from his diet being the only change we made, and though his other foot is in a none-too-healthy state, it hasn't got worse in all that time, in fact a slight improvement over several years is noted, in that they can pick up a pulse where they couldn't without a Doppler before.
Right, so there is his blood pressure. Already on Atenolol since the heart attack, put on Perindropril after the stroke, along with Atorvastatin and Bezafibrate and Clopidogrel (Plavix). When first put on Peridopril, it was controlled as always, starting on 2mg, then 4mg then 8mg, but he felt ill after 8mg so the doctor reduced the dose to 6mg after low BP reading, and suggested 6mg was his limit of tolerance.
Last year he showed a small excess of protein in his urine. so he was referred to the renal doctor, and given an ultrasound scan. There we discovered he only has one kidney, 15% larger but still only one. However the renal doctor discharged him in that it was only slight and the diabetes was clearly in good control, to be monitored annually. GP raised his Perindopril to 8mg in spite of my protests saying there is a reason he was on 6 and not 8 for all these years. But it's an Ace Inhibitor, this is for his kidney now.
His BP rose, almost immediately. I have to add it had been normal for all the years he was on 6mg. I suggested that research shows a very few patients do have this and again, he is now above his tolerance. (levels of blood enzyme Renin causes the reverse effect in between 7% and 16% of patients) They disagreed. In fact, they put him on 10mg. Needless to say this also had no effect on his BP, so they raised his Atenolol to 75mg daily. No effect. In June this year, he was put on Lansoprazole as Ranitidine was no longer available. He's also on aspirin so this is something he has been taking since the heart attack I think. In July, Atenolol was raised to 100mg daily, and whilst still on Perindopril 10mg which clearly wasn't working he had Amlodipine 5mg added to the mix. Within a week of taking Amlodipine he suffered diarrhoea which got worse over the next three weeks until it became so explosive he lost all bowel control. He refused to take any more Amlodipine, his BP was still high anyway, and we called the GP who agreed. However a week later it was as bad as ever, removing Amlodipine had no effect. Samples were taken both general and a 'Fit' test. infection was ruled out and there was no blood or signs that it could be something nastier. GP came on a home visit to perform rectal and abdominal examination, no lumps or constipation blockage found. By this time I knew his glucose levels were dropping, he was confused and slurred. However his refusal to test meant I had no lancets and strips so I had to work with what I had. He refused to eat, though was drinking 4-5 pints of water a day, but did try a couple of biscuits and a sweet drink, I also put a half tsp sugar in his coffee over a period of an hour, to raise it slower, and it seemed fine, he was ok. He chose to have a slice of toast with a thin spread of jam on, (up till then he had only eaten dry toast). GP prescribed immodium and told me to stop his Gliclazide. I went to the chemist next day to get it, making sure he was ok for the hour it was going to take. He was fine as I left. When I got back he was unconscious. I had to revive him with sugar and a sweet drink, but as often happens, a spike and then a crash a couple of hours later. Then he revived again, then vomited, then passed out over the loo. I called the ambulance, paramedics put him on a drip and it took 2 hours to get his levels up to 5.0. They took him in,. where it was found he was suffering stage 2 Acute Kidney Injury due to dehydration. They took him off ALL medication only re-introducing most of them on discharge.
So he was discharged from hospital, and kept OFF Gliclazide and Metformin and Perindopril. To be reviewed in two weeks, and if needed to be put back on Metformin, but if the diarrhoea starts again, they should try a gliptin.
However it's now three weeks since discharge, and we have not been able to give him any diabetes meds, even though his readings are average 13.5 daily. I'm testing three times a day, no major spikes, but it varies between 9.5 and 16. GP said as long as it doesn't go more wildly than that he can sustain it for a while longer until we get the diarrhoea stopped. Suggested perhaps taking him off Lansoprazole to see if that makes a difference.
Voila! 36 hours later, no more diarrhoea, no more lack of bowel control. 48 hours and we have two dry nights.
We have a consultation with gastro-enterology, who are leaning toward Inflammatory Bowel Disease, I'm leaning toward a microscopic colitis, possibly collagenous colitis and Lansoprazole seems to be top of the list of irritant medications in that.
So here's my question. I'm not keen on him going back to metformin if a gliptin is a viable alternative, as suggested by the hospital, which one can I push for? I'm hearing good things about it, and perhaps this is what he needs to continue with better control of his T2. But while the GPs are finally in a mood to actually listen I'd like to discuss it as a possibility. Chris doesn't particularly want to go back on Metformin, and is adamant that Perindopril is not going anywhere near his mouth, that frightened him badly. I've said he might have to for his kidney, but no more than 6mg. and the GP agreed it would only be reintroduced in a very controlled manner.
So what type of Gliptin has shown good results? Is it a viable alternative to using Metformin? Does anyone use Gliptins instead of Metformin or alongside it? Give me a name I can suggest at our next consultation. please.
