Latest HbA1c and surgery review

[Sussexmax]

Just had an appointment with my GP to review my latest blood test which to my surprise has dropped a little further to 33 this time. She said she was really pleased with the result and that we just need to keep things going as they are. I asked about possibly reducing my medication but she said as the diabetes is ‘well controlled’ it’s better to leave things as they are.

Every time I read about someone reversing their diabetes without meds or going into remission after coming off medication it makes me feel left behind and wishing it was me! I remember reading that remission is most likely within five years and I’m now approaching four years since diagnosis, so is time running out?

Should I have pushed more to reduce or come off medication, or should I be content that everything is going well and that the metformin and rybelsus have other benefits beyond diabetes control. She’s changed me to annual testing now, so I suppose I’ve missed the opportunity for a year anyway!

 

[rebrascora]

It is important for you to express how you feel and what you would like to achieve with your doctor. Ultimately it is up to you whether you take whatever medication you are prescribed, not that I am encouraging you to disregard your GP's advice, but only you know how sustainable your lifestyle changes are to maintain that fantastic HBA1c result. Unfortunately doctors mostly assume the medication is doing most/all of the work and have no understanding of how effective dietary and lifestyle changes can be, so it is understandable that they are reluctant to mess with medication which they see as being successful. Ideally what you should have done is gone into the appointment with a plan of action and steered the appointment in that direction, so perhaps, suggesting dropping one of the medications for a period of 3 months and having a follow up HbA1c at the end of that period to see if there was any marked increase in your result.

As you say, that opportunity has been lost to a large extent.
Your options are:-
To fully comply with your GP and continue as things are for another year
OR
To contact your GP perhaps via email and express what you actually want to do and why and that you are very committed to your lifestyle changes and would like to try to come off meds if possible and ask for a 3 month HbA1c test and review to monitor how things are going with reduced meds
OR
You make your own decisions and do what you feel is right for you and if that is reducing your meds, then doing so within a framework which allows you to monitor your levels (home BG testing) and perhaps have a private HbA1c test after 3 months to see how things are working out, with the opportunity to resume your previous medication.

I am not trying to guide you one way or another, but just outlining your options as I see them.

 

[rebrascora]

Many congratulations on your great HbA1c result by the way!

 

[Martin.A]

Yet my DN, when she saw how my numbers were going, told me I could stop taking my Metformin. I'm always bemused by the inconsistencies around diabetes across the NHS.

 

[ColinUK]

I second emailing your GP. It’s the generally far easier to explain things and to get your point of view across via email than it is in a time-pressured appointment.

 

[Sharron1]

Just had an appointment with my GP to review my latest blood test which to my surprise has dropped a little further to 33 this time. She said she was really pleased with the result and that we just need to keep things going as they are. I asked about possibly reducing my medication but she said as the diabetes is ‘well controlled’ it’s better to leave things as they are.

Every time I read about someone reversing their diabetes without meds or going into remission after coming off medication it makes me feel left behind and wishing it was me! I remember reading that remission is most likely within five years and I’m now approaching four years since diagnosis, so is time running out?

Should I have pushed more to reduce or come off medication, or should I be content that everything is going well and that the metformin and rybelsus have other benefits beyond diabetes control. She’s changed me to annual testing now, so I suppose I’ve missed the opportunity for a year anyway!

Ohh, your GP sounds like mine As you can see my HbA1c numbers are good and when I tentatively ask about reducing Met the reply I get is if it ain't broke don't fix it. Last year I spoke with the Prescribing Pharmacist who did reduce Met by 1, I now take three She was slightly huffy that nobody had done it earlier Good luck

 

[Sussexmax]

It is important for you to express how you feel and what you would like to achieve with your doctor. Ultimately it is up to you whether you take whatever medication you are prescribed, not that I am encouraging you to disregard your GP's advice, but only you know how sustainable your lifestyle changes are to maintain that fantastic HBA1c result. Unfortunately doctors mostly assume the medication is doing most/all of the work and have no understanding of how effective dietary and lifestyle changes can be, so it is understandable that they are reluctant to mess with medication which they see as being successful. Ideally what you should have done is gone into the appointment with a plan of action and steered the appointment in that direction, so perhaps, suggesting dropping one of the medications for a period of 3 months and having a follow up HbA1c at the end of that period to see if there was any marked increase in your result.

As you say, that opportunity has been lost to a large extent.
Your options are:-
To fully comply with your GP and continue as things are for another year
OR
To contact your GP perhaps via email and express what you actually want to do and why and that you are very committed to your lifestyle changes and would like to try to come off meds if possible and ask for a 3 month HbA1c test and review to monitor how things are going with reduced meds
OR
You make your own decisions and do what you feel is right for you and if that is reducing your meds, then doing so within a framework which allows you to monitor your levels (home BG testing) and perhaps have a private HbA1c test after 3 months to see how things are working out, with the opportunity to resume your previous medication.

I am not trying to guide you one way or another, but just outlining your options as I see them.

Thanks for your really thoughtful reply, and it’s very useful for someone slightly removed from the situation to give suggestions and options. If I did reduce the meds for three months or so and then get a private HbA1c done, I wonder whether the NHS and surgery would be advised? I wouldn’t want to look like I was ‘doing my own thing’. I could try emailing to ask if I could reduce or stop the medication, but I’d feel very awkward as I’d said I was really pleased to be allowed to go to annual reviews! Maybe I’ll have to accept that this time, and see what my score is next year - especially as I’m just about at my planned weight, so will be less strict as far as diet is concerned. There’s probably no right or wrong answer…

 

[Sussexmax]

Yet my DN, when she saw how my numbers were going, told me I could stop taking my Metformin. I'm always bemused by the inconsistencies around diabetes across the NHS.

That’s so true! Everyone seems to be told something slightly different. Did you see a spike in your score when you stopped taking the metformin?

 

[Sussexmax]

I second emailing your GP. It’s the generally far easier to explain things and to get your point of view across via email than it is in a time-pressured appointment.

I’m still considering the options, but as I said in another reply I’d feel really awkward as was so pleased to be going to yearly checks! Might need more planning before the next review, to have my suggestions ready!!

 

[Sussexmax]

Ohh, your GP sounds like mine As you can see my HbA1c numbers are good and when I tentatively ask about reducing Met the reply I get is if it ain't broke don't fix it. Last year I spoke with the Prescribing Pharmacist who did reduce Met by 1, I now take three She was slightly huffy that nobody had done it earlier Good luck

Thank you! You’re spot on about GPs not wanting to change things, although she is very approachable. Seems much easier to get put on medication than it is to come off it! Think I remember your trials and tribulations with the metformin last year, how’s it going… have you seen any changes in your levels?

 

[Martin.A]

That’s so true! Everyone seems to be told something slightly different. Did you see a spike in your score when you stopped taking the metformin?

My numbers nudged up a little at first but then dropped back and my graph has been pretty flat since.

 

[Zaentzpantz]

I have similar problems with two of my GPs.
Last November type 2 was diagnosed at A1c of 131mmol/mol and metformin at 2gms/ day was prescribed ( four 500mg tablets).
By Christmas it was down to 108, and by February it was 50. Last month it was 47, below the NHS target of 48mmol/ mol.
When I asked about reducing the dosage from the maximum of 2gm/ day I was told not to, by both GPs.
I'm not keen on unnecessary medication and would like to minimise the intestinal discomfort from taking metformin. Are my GPs odd?
I did ask about the possibility of future remission but the reaction from my DN and GP was as if I had requested a course of witchcraft and was swiftly dismissed. Are Diabetes UK out on a limb with this idea of remission?

 

[wantonnoodle]

@Zaentzpantz I would say that's normal from the part of the GP/DN. 47 is still in the prediabetic range. I had an HbA1c of 46 at my review in December, and when I asked if I could reduce my metformin from the 4 tablets a day, the nurse said that I would need to be out of the lower end of the prediabetic range (so below 42) before I could reduce it.

From what I've seen/heard from other type 2s who have had success reducing meds, generally in most cases, they've had HbA1c readings in the 30s when they started to reduce meds. So I wouldn't be overly upset by the resistance to reduce meds.

 

[Zaentzpantz]

So why does the NHS NICE website rrcommend 48 as the target value?
My GP tells me that is the preferred value for type 2 patients, whereas the 20-41 range is for non-diabetic patients. Is that right?

 

[Sharron1]

Thank you! You’re spot on about GPS not wanting to change things, although she is very approachable. Seems much easier to get put on medication than it is to come off it! Think I remember your trials and tribulations with the metformin last year, how’s it going… have you seen any changes in your levels?

Ohh, I have that excitement yet to come in October, no doubt with the addition of the Statin 'chat' My bet is they don't read my notes re my Liver and avosomething statin. Sigh. Still i have a few months not to think about it.

 

[Leadinglights]

So why does the NHS NICE website rrcommend 48 as the target value?
My GP tells me that is the preferred value for type 2 patients, whereas the 20-41 range is for non-diabetic patients. Is that right?

I do find this very peculiar that what is considered an acceptable level for those diagnosed with Type 2 is the same that would give people a diagnosis rather that what would be a normal level of below 42mmol/mol but that does seem to be the accepted definition of remission, 2 consecutive HbA1C results below 48mmol/mol without medication.
I personally don't feel comfortable with that as it is too close for comfort to being over that threshold into the diabetic zone.
Below 42mmol/mol is normal level, some people do get down to mid thirties but not usually as low as 20 but if not diabetic then people may be at that level.

 

[Sussexmax]

Thanks to all that have replied with thoughts and advice, it’s much appreciated. Can I ask another question based around my probable way forward - certainly for the next year… Is there anything concerning or worrying about keeping on with medication compared to reducing or coming off them?

 

[rebrascora]

The only thing with Metformin is that taking it long term can impact your ability to absorb vitamin B12 from your food or any supplements you take. If you become deficient in vitamin B12 that can impact nerve health and cause pins and needles or other discomfort. It is a known possible side effect of Metformin and B12 is usually checked at your annual review and if you are deficient then injections are necessary to boost your levels. The problem is usually reversible with increased B12 levels. I don't know anything much about Semaglutide. That is one of the appetite suppressing drugs isn't it? I think there is a very, very slight risk of pancreatitis or thyroid cancer with some of that family of drugs if I remember correctly, but the risk is incredibly low. If you read the patient information leaflet it should list possible side effects.
I think we tend to consider side effects as something that happens straight away when we take them, but there can be possible longer term impacts from taking medication which are also side effects. I have also heard it said that there are potential benefits to the heart from taking Metformin so you might have additional gains as well as some possible detrimental effects.

 

[Sussexmax]

The only thing with Metformin is that taking it long term can impact your ability to absorb vitamin B12 from your food or any supplements you take. If you become deficient in vitamin B12 that can impact nerve health and cause pins and needles or other discomfort. It is a known possible side effect of Metformin and B12 is usually checked at your annual review and if you are deficient then injections are necessary to boost your levels. The problem is usually reversible with increased B12 levels. I don't know anything much about Semaglutide. That is one of the appetite suppressing drugs isn't it? I think there is a very, very slight risk of pancreatitis or thyroid cancer with some of that family of drugs if I remember correctly, but the risk is incredibly low. If you read the patient information leaflet it should list possible side effects.
I think we tend to consider side effects as something that happens straight away when we take them, but there can be possible longer term impacts from taking medication which are also side effects. I have also heard it said that there are potential benefits to the heart from taking Metformin so you might have additional gains as well as some possible detrimental effects.

Thank you @rebrascora. I was thinking more about the metformin because my GP and I have discussed the semaglutide and agreed that it wouldn’t be long term, so maybe just one more year until I reach my goal in weight loss. Whether it will get replaced or simply withdrawn is of course another question!! One of the positives about staying on metformin is indeed its cardio benefits. I suppose I’m also questioning whether the longer I’m on diabetes medication, the less likely I will be to ever get into remission. At least I’m more accepting of the fact that I’m now diabetic - if that does prove to be the case!

 

[rebrascora]

As far as I can see, the medication should not prevent you achieving remission at a later date provided that your diabetes is well managed and you are not putting your beta cells under undue pressure by eating more carbs than they can cope with. I think remission is less achievable if diabetes is long term and poorly managed, so I don't think you are less likely to achieve remission by ticking over as you are with medication for another year when your HbA1c is in the normal range.