Level at which Metformin is prescribed

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Teadance

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Hi, I’ve just had a phone call from Diabetic nurse to discuss my HbA1c increase to 53. I can’t think of any reason it has gone up, but she said they give medication when it gets to 48. I haven’t been offered it before, even when it was 49. Does anyone know if there is a level at which medication is routinely given? I’d like to avoid it if possible.
 
According to the NHS website Metformin is usually prescribed when diet and exercise alone have not been enough to control blood sugar levels. Have you been managing through diet & exercise, yet have still seen a rise?
 
Teadance said:
Hi, I’ve just had a phone call from Diabetic nurse to discuss my HbA1c increase to 53. I can’t think of any reason it has gone up, but she said they give medication when it gets to 48. I haven’t been offered it before, even when it was 49. Does anyone know if there is a level at which medication is routinely given? I’d like to avoid it if possible.
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I think it all depends on the protocols used at your surgery rather than there being any nationwide rules or regulations.
 
Martin.A said:
According to the NHS website Metformin is usually prescribed when diet and exercise alone have not been enough to control blood sugar levels. Have you been managing through diet & exercise, yet have still seen a rise?
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Erm, my hba1c was 74 at diagnosis (not even sure if it was my blood sample tested but that is another long story which I have retold many times) straight on to Metformin. No mentionn of anything. Wish I had some of the info I have now, I would have asked more questions rather than simply sitting and agreeing with stuff I didn't really understand. 5 years later I still have seen the GP whose expertise is Diabetes. Impossible to get an appointment for a few minutes chat to ask some questions, the surgery nurse although very pleasant doesn't really know that much about diabetes.
 
Sharron1 said:
Erm, my hba1c was 74 at diagnosis (not even sure if it was my blood sample tested but that is another long story which I have retold many times) straight on to Metformin. No mention of anything.
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I would expect medication to be prescribed for a 74 at diagnosis but @Teadance was at 49 without meds and has now crept up to 53, so whatever regime they're following is no longer working, or so it seems to their DN.
 
Martin.A said:
I would expect medication to be prescribed for a 74 at diagnosis but @Teadance was at 49 without meds and has now crept up to 53, so whatever regime they're following is no longer working, or so it seems to their DN.
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I agree at 74 it is usually prescribed but my smallish moan is that no other option was even mentioned. The diagnosis discussion (originally confirmed by the surgery receptionist. Don't ask) took about two minutes and I left with a prescription and a banging headache
 
Martin.A said:
According to the NHS website Metformin is usually prescribed when diet and exercise alone have not been enough to control blood sugar levels. Have you been managing through diet & exercise, yet have still seen a rise?
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Yes, I’ve been managing it with diet and exercise so far. I’m surprised it’s gone up as I really thought I was managing it. I’m being very strict with my diet now though, in the hope that I can reduce it again and stay off medication.
 
Sharron1 said:
Erm, my hba1c was 74 at diagnosis (not even sure if it was my blood sample tested but that is another long story which I have retold many times) straight on to Metformin. No mentionn of anything. Wish I had some of the info I have now, I would have asked more questions rather than simply sitting and agreeing with stuff I didn't really understand. 5 years later I still have seen the GP whose expertise is Diabetes. Impossible to get an appointment for a few minutes chat to ask some questions, the surgery nurse although very pleasant doesn't really know that much about diabetes.
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That doesn’t sound great. I must admit I often quote the previous diabetic nurse’s advice as I left her room. ‘Don’t eat pies’!
 
Teadance said:
Yes, I’ve been managing it with diet and exercise so far. I’m surprised it’s gone up as I really thought I was managing it. I’m being very strict with my diet now though, in the hope that I can reduce it again and stay off medication.
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I'm pretty much in the same boat, though I wasn't surprised as it covered a period when we had a week in Pembrokeshire in July and a week in Cornwall in August. I always find it more difficult to keep to my diet & exercise regime when away from home. Been much stricter with it since the back end of last year.
 
If you haven't got a home testing blood glucose monitor then you would benefit from having one so you can test the effect of foods and meals as what you have been having in terms of the amount of carbohydrates has been too much for you to tolerate and testing would help you find which food you need to avoid or reduce your portions of.
Even at 53 mmol/mol you should be able to bring it down with a bit more attention to your diet and should be given the opportunity.
 
Martin.A said:
I'm pretty much in the same boat, though I wasn't surprised as it covered a period when we had a week in Pembrokeshire in July and a week in Cornwall in August. I always find it more difficult to keep to my diet & exercise regime when away from home. Been much stricter with it since the back end of last year.
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I’ve tried to think back to the previous months but can’t remember having any huge lapses but it is insidious so maybe I did. I’m definitely back on it now and have been for about 5 weeks. I really hope it makes a difference.
 
Leadinglights said:
If you haven't got a home testing blood glucose monitor then you would benefit from having one so you can test the effect of foods and meals as what you have been having in terms of the amount of carbohydrates has been too much for you to tolerate and testing would help you find which food you need to avoid or reduce your portions of.
Even at 53 mmol/mol you should be able to bring it down with a bit more attention to your diet and should be given the opportunity.
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I do test and my morning results have been in the 5s so I didn’t think there was a problem. I try to avoid too many carbs but clearly will have to be stricter if I’m to avoid medication.
 
Teadance said:
Hi, I’ve just had a phone call from Diabetic nurse to discuss my HbA1c increase to 53. I can’t think of any reason it has gone up, but she said they give medication when it gets to 48. I haven’t been offered it before, even when it was 49. Does anyone know if there is a level at which medication is routinely given? I’d like to avoid it if possible.
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They give it when diet and exercise haven’t been enough. When you were 49 you must have been advised to improve diet and exercise but now that isn’t enough any more. Either that or the guidelines have changed since your a1c of 49
 
Lucyr said:
They give it when diet and exercise haven’t been enough. When you were 49 you must have been advised to improve diet and exercise but now that isn’t enough any more. Either that or the guidelines have changed since your a1c of 49
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According to current NICE guidelines a target HbA1c level of 48 mmol/mol is generally recommended when type 2 diabetes is managed by diet and lifestyle alone, so your conclusion may be right. The current guidelines are dated June 2022.
 
Lucyr said:
They give it when diet and exercise haven’t been enough. When you were 49 you must have been advised to improve diet and exercise but now that isn’t enough any more. Either that or the guidelines have changed since your a1c of 49
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Yes it’s possible the guidelines have changed. I’m on it now though, and have been offered a retest in 3 months and an opportunity to see a specialist diabetic nurse week after next to see if my diet can be tweaked. Will try those before accepting medication if I can.
 
I've never seen an exact number for when they prescribe medication, having checked the NICE guidelines and my local Health Trust guidelines. I think when people are diagnosed pre-Diabetic, they advise lifestyle changes, but when fully Diabetic it's up to their discretion. So if the HbA1c is below 42 non-Diabetic, 43-47 pre-diabetic, 48 or over Diabetic. My HbA1c was 79 at diagnosis. The GP who diagnosed Diabetes said I can try lifestyle changes or try them with medication as well, but I need to see the DSN (Diabetic Specialist Nurse). When I saw the DSN, she advised I definitely continue with the lifestyle changes, which I'd already started and take Metformin. I would guess if someone is Diabetic but at the lower end of the HbA1c, but very overweight and sedentary, they might choose medication as well as advising lifestyle changes. Where if they at the lower end of the HbA1c, but are fairly active and not too overweight, they might just advise lifestyle changes. They also consider other pre-existing health issues, particularly cardiovascular issues as well as risks. But at the end of the day it's your choice, if you feel you need, or don't need medication, talk to them about it.
 
The treatment is supposed to be 'individualised' based on working out a target hba1c and then using lifestyle changes and/or drugs to get to it. If lifestyle changes can't get you to the target, then medication may be needed, and the sort of medication used may depend upon other risk factors. The higher the hba1c, the higher the risk of complications, which is something that is weighed up as part of the 'individualised' treatment.

So the level at which you may want to start drug therapy is something you'd have to decide upon based on a target hba1c.

It doesn't necessarily have to be in the 'non diabetic' or 'pre-diabetic' range - I know someone whose target is in the 50s.
 
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