When to lower metformin

[Libby17]

In feb my blood sugar readings were between 9 and 13. I am on low carb and intermittant fasting diet, since feb I have lost 2 stone. My blood sugar readings have all been in the 4s and 5s for the last couple of weeks, I start to feel a little shaky when it goes down to 4.2' I am on 1000mg of metformin twice a day. At what stage would one usually start to reduce medication?

 

[Leadinglights]

In feb my blood sugar readings were between 9 and 13. I am on low carb and intermittant fasting diet, since feb I have lost 2 stone. My blood sugar readings have all been in the 4s and 5s for the last couple of weeks, I start to feel a little shaky when it goes down to 4.2' I am on 1000mg of metformin twice a day. At what stage would one usually start to reduce medication?

Welcome to the forum
I would be wise to have an HbA1C test before making any decisions about reducing the medication as that will give a better assessment of where you now are rather than finger prick readings. But in any case it would be a good idea to discuss with your nurse or GP.

 

[Libby17]

Welcome to the forum
I would be wise to have an HbA1C test before making any decisions about reducing the medication as that will give a better assessment of where you now are rather than finger prick readings. But in any case it would be a good idea to discuss with your nurse or GP.

I spoke to my dr and he said not until my readings get below 4. My HB1ac was 85 in feb, 55 at the end of June 6 weeks ago, is it too early to ask for another one ? My dr wasnt very encouraging, told me not to get my hopes up as he could count on the fingers of one hand the people he knew that had managed remission and that i wasnt to have unrealistic expectations ! Im more determined than ever to prove him wrong.

 

[Lucyr]

My HB1ac was 85 in feb, 55 at the end of June 6 weeks ago, is it too early to ask for another one ?

Yes it is. Hba1c needs to be done at least annually, but shouldnt be done more than quarterly. Generally they tend to be done either 6 or 12 monthly

 

[Leadinglights]

If your HbA1C is 55 mmol/mol then you are still in the diabetes zone, the threshold is 47mmol/mol so it is really only when people are getting well below that that reduction in medication is normally considered indeed really when people are in normal range of below 42mmol/mol. As you say he is being rather negative but don't be discouraged as he may be one of those GPs who don't believe how powerful dietary changes and a low carb way of eating can be in reducing blood glucose.

 

[Libby17]

If your HbA1C is 55 mmol/mol then you are still in the diabetes zone, the threshold is 47mmol/mol so it is really only when people are getting well below that that reduction in medication is normally considered indeed really when people are in normal range of below 42mmol/mol. As you say he is being rather negative but don't be discouraged as he may be one of those GPs who don't believe how powerful dietary changes and a low carb way of eating can be in reducing blood glucose.

Thankyou, I think my HB1ac will has reduced further in the last 6 weeks , what does HB1ac 42 equate to in blood sugar readings that i take at home?

 

[Leadinglights]

Thankyou, I think my HB1ac will has reduced further in the last 6 weeks , what does HB1ac 42 equate to in blood sugar readings that i take at home?

It doesn't because they measure different things. HbA1C is an average of blood glucose (glucose stuck to your red blood cells) over the previous 3 months, whereas your finger prick is a moment in time. The more consistently your readings are between 4-7mmol/l before meals and fasting and 2 hour post meal readings are no more than 8 mmol/l the ore likely your HbA1C will be in normal range.

 

[Libby17]

It doesn't because they measure different things. HbA1C is an average of blood glucose (glucose stuck to your red blood cells) over the previous 3 months, whereas your finger prick is a moment in time. The more consistently your readings are between 4-7mmol/l before meals and fasting and 2 hour post meal readings are no more than 8 mmol/l the ore likely your HbA1C will be in normal range.

Thankyou for your reply, My blood sugar readings range between 4.2 and 6 mmol before meals fasting and an average of 6.6mmol
2 hours post meal, I have only had 1 reading of 7mmol in the last 2 weeks

 

[Leadinglights]

Thankyou for your reply, My blood sugar readings range between 4.2 and 6 mmol before meals fasting and an average of 6.6mmol
2 hours post meal, I have only had 1 reading of 7mmol in the last 2 weeks

That is looking good for a good HbA1C when you have it. Better to wait 3 months after the last one before you have it.

 

[Libby17]

That is looking good for a good HbA1C when you have it. Better to wait 3 months after the last one before you have it.

Thankyou for your advice

 

[childofthesea43]

If your HbA1C is 55 mmol/mol then you are still in the diabetes zone, the threshold is 47mmol/mol so it is really only when people are getting well below that that reduction in medication is normally considered indeed really when people are in normal range of below 42mmol/mol. As you say he is being rather negative but don't be discouraged as he may be one of those GPs who don't believe how powerful dietary changes and a low carb way of eating can be in reducing blood glucose.

I would like it to be more widely acknowledged that these thresholds of <42 and <48 apply to people under 40, but for those in their sixties or older those thresholds need to be at least 6 mmol/mol higher. At age 75 my usual A1c of 41 is not near pre-diabetic but very comfortably below that. The research on this point seems incontestable and hcps need to wake up to it so as not to misdiagnose or overtreat those in their later years. So I’d hope to see an end in this forum to the same old numbers always being trotted out without considering the age factor.

 

[Dragonheart]

I would like it to be more widely acknowledged that these thresholds of <42 and <48 apply to people under 40, but for those in their sixties or older those thresholds need to be at least 6 mmol/mol higher. At age 75 my usual A1c of 41 is not near pre-diabetic but very comfortably below that. The research on this point seems incontestable and hcps need to wake up to it so as not to misdiagnose or overtreat those in their later years. So I’d hope to see an end in this forum to the same old numbers always being trotted out without considering the age factor.

The latest NICE guidance does indeed make allowances to 53mmol for certain situations, though no specific age is mentioned, but also says if a person is achieving lower levels without hypos then to encourage them to maintain this lower level. In this day and age of cgm its much easier to prove a good hba1c is happening because of good even control rather than because of hypos and highs.

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

www.nice.org.uk

 

[childofthesea43]

The latest NICE guidance does indeed make allowances to 53mmol for certain situations, though no specific age is mentioned, but also says if a person is achieving lower levels without hypos then to encourage them to maintain this lower level. In this day and age of cgm its much easier to prove a good hba1c is happening because of good even control rather than because of hypos and highs.

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

www.nice.org.uk

However NICE has not yet recognized the research showing that older non-diabetics present rising HbA1c due to changes in red cell turnover. In such circumstances finger pricking becomes a better indicator of blood glucose levels than HbA1c.

 

[Leadinglights]

You all make very good points but you do see people who are of more mature years with HbA1C at diagnosis of low 50ies and still being prescribed metformin.

 

[Dragonheart]

However NICE has not yet recognized the research showing that older non-diabetics present rising HbA1c due to changes in red cell turnover. In such circumstances finger pricking becomes a better indicator of blood glucose levels than HbA1c.

True. Nice always takes a while to catch up on research findings. HbA12 and blood glucose are measuring different things and each have their disadvantages or limitations. Non average (12 weeks) rbc turnover being one of the biggies for hba1c, alongside the lack of nuance between high/low extremes v steady levels.

Do you have a link or reference to the slowing of rbc with age research?

 

[childofthesea43]

True. Nice always takes a while to catch up on research findings. HbA12 and blood glucose are measuring different things and each have their disadvantages or limitations. Non average (12 weeks) rbc turnover being one of the biggies for hba1c, alongside the lack of nuance between high/low extremes v steady levels.

Do you have a link or reference to the slowing of rbc with age research?

Yes, see the paper published in the journal BMC Endocrine Disorders on 12 Feb 2019 by Masuch et al, as one example.

 

[harbottle]

I spoke to my dr and he said not until my readings get below 4. My HB1ac was 85 in feb, 55 at the end of June 6 weeks ago, is it too early to ask for another one ? My dr wasnt very encouraging, told me not to get my hopes up as he could count on the fingers of one hand the people he knew that had managed remission and that i wasnt to have unrealistic expectations ! Im more determined than ever to prove him wrong.

My dose was halved from 1000mg to 500mg when I got a 2nd hba1c of 36 after an 83 and being put on 1000mg of Metformin - not sure why it was such a low dose when 83 is fairly high, and it seems to be debatable if 1000mg is effective.

They said I could stop last year if I wanted, as it was still in the 30s. I decided to keep taking it, as it's not doing me any harm. It's still in the 30s this year.

Below 4 seems odd. I get readings in the 3s quite often after exercise (And if I drink alcohol), and I've been told to eat something sugary when it goes below 4! I don't, because it goes up to the 5s after a short period of time.

Your Dr is right. Remission/reversal is a bit controversial and not everyone can achieve it, and many who do fail to maintain the relevant lifestyle necessary remain in remission. I have a friend who is a GP and has never seen anyone do it, although most T2s take the pills and don't change their lifestyle. ("Diet for a few weeks and then back on the pizza!")

 

[childofthesea43]

My dose was halved from 1000mg to 500mg when I got a 2nd hba1c of 36 after an 83 and being put on 1000mg of Metformin - not sure why it was such a low dose when 83 is fairly high, and it seems to be debatable if 1000mg is effective.

They said I could stop last year if I wanted, as it was still in the 30s. I decided to keep taking it, as it's not doing me any harm. It's still in the 30s this year.

Below 4 seems odd. I get readings in the 3s quite often after exercise (And if I drink alcohol), and I've been told to eat something sugary when it goes below 4! I don't, because it goes up to the 5s after a short period of time.

Your Dr is right. Remission/reversal is a bit controversial and not everyone can achieve it, and many who do fail to maintain the relevant lifestyle necessary remain in remission. I have a friend who is a GP and has never seen anyone do it, although most T2s take the pills and don't change their lifestyle. ("Diet for a few weeks and then back on the pizza!")

My own view is that it is irresponsible for a GP to dole out the pills to a newly diagnosed T2 until that T2 has demonstrated that their blood glucose remains elevated even after they have brought their weight down by 15% or so, because otherwise those pills will lead the T2 down a road in which remission will become impossible, the pills will no longer be enough and the road ends in the way we all know.

 

[DiabloT2]

I spoke to my dr and he said not until my readings get below 4.

I didn't get readings lower than 4 from finger prick readings and my HBA1c fell to below 40. Its remained there for about 2 years and the only ever time since that I have had a reading below 4 was when I did a 3 day fast. I don't know if there are other factors influencing why your dr has said your readings need to get below 4, but to me it would seem overly stringent especially if your HBAC1c falls below 42. Many folks in remission, myself included, get finger prick readings pretty similar to yours.

 

[everydayupsanddowns]

I didn't get readings lower than 4 from finger prick readings and my HBA1c fell to below 40. Its remained there for about 2 years and the only ever time since that I have had a reading below 4 was when I did a 3 day fast. I don't know if there are other factors influencing why your dr has said your readings need to get below 4, but to me it would seem overly stringent especially if your HBAC1c falls below 42. Many folks in remission, myself included, get finger prick readings pretty similar to yours.

Yes I was surprised at the Dr’s suggestion of below 4 - which is often used as a warning level for impending hypoglycaemia, rather than a BG level to be normally expected?