Medication not working

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dianewms Posted: Tue, Jul 21 2009 9:37 PM

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I am newly diagnosed diabetes 2.  Im on 750 metformin twice a day and 2.5 glyburide in the morning.  When I first start on a new dosage it works for a few weeks then my sugar starts rising again.  My Dr told me I would go on insulin this Monday if It was still not under control.  Is that premature?  I know I can still go up on dosages.  Is the fact that the sugar starts rising again a sign I need insulin?  I dont want to do insulin if I dont have to.  ADVICE AND OPINIONS PLEASE

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Simi_Papa replied on Wed, Jul 22 2009 12:52 AM

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Tell your doctor you want to increase your Metformin to the maximum amount.  You might want to ask about adding Prandin, which is taken before meals and stimulates insulin production for a short period of time to cover the carbs you eat.  How are you doing on weight loss and exercising?  What diet are you using?  This seems premature to me as well to add insulin after such a short period of time.

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jen1229 replied on Wed, Jul 22 2009 8:51 AM

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Some people require insulin sooner than others.  It is not a failure to have to go on insulin.   It is likely the doctor has a reason for sggesting insulin and you should discuss this with him/her. 

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dianewms replied on Wed, Jul 22 2009 9:52 AM

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Thanks,

I am on another medication that causes sugar to rise and its one I need.  I think this may be the reason for suggesting insulin.  I do feel like a failure.  Ive done everything including losing 20 pounds and people are still treating me like Im cheating.  Even my husband.

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dianewms replied on Wed, Jul 22 2009 9:55 AM

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I am thiking the way you are.  I have lost 20 pouinds and walk regularly.  However I am also on seroquel which is known to cause sugar to rise.  I need it and it would be a major extended ordeal to get off it.  Im going to have a frank discussion with the Dr.  My dosage has been raised 3 times already and eachtime my sugar has creeped up after about three weeks.

I feel like a failure and have never had something like this that I couldnt control.

Thanks for your input,

Diane

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Ron AKA replied on Wed, Jul 22 2009 11:17 AM

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Diane, I did a little reading on the Seroquel that you are taking, and yes it has been associated with an increase in blood glucose in some cases. See section 5.4 on page 3 of the prescribing information for Seroquel. However, at least on average the effect does not seem that significant. You may be one of the exceptions however.

To make some sense of it requires more information. How long have you been treated with metformin and glyburide? Also how long on the Seroquel? What is the dose of the metformin and glyburide? What kind of BG tests were done; fasting, oral glucose tolerance test, A1C? What were the results? Are you monitoring your BG with a home meter? What is your home meter fasting level? Two hours after meals?

There is no reason to feel like a failure even if you have to take insulin. It is much more important to make sure your BG is properly controlled. Hang in there, as I'm sure there are solutions.

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dianewms replied on Wed, Jul 22 2009 11:41 AM

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Ive been on seroquel for 2 years.  One year ago my A1c was a 6.8.  This year an 8.  Ive been on metformin starting out at 250 mg twice a day for 3 months.  Now I am on 750 twice a day and glyburide 2.5 once a day.  The a1C is down to a 6.8 again.  because of the seroquel they told me I would go on once a day insulin at my next appt on Monday.  Im controlled on meds for the first few weeks of a dosage change.  This morning my sugar level was 190.  It stays between 120-160 during the day.  about 160 after dinner.  I feel like crap.

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Ron AKA replied on Wed, Jul 22 2009 12:35 PM

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First, those BG numbers are too high, and a treatment change is required. The hard part about type 2 diabetes is determining whether the problem is caused by insufficient insulin or high resistance to insulin. Knowing which one it is, helps in determining which type of drug is most effective in treating it. The metformin you are taking increases sensitivity to insulin by a moderate degree, and to a larger degree inhibits the liver from dumping too much sugar into the blood. It also slows digestion of carbs somewhat. You are not that close to the maximum dose of metformin which is 2550 mg per day. However, little additional benefit is seen after 2000 mg per day. The glyburide stimulates insulin production essentially for 24 hours per dose. Depending on the type max dose is 12 or 20 mg per day, but either way you are no where near the max. The down side of glyburide is that if you take too much you can have low BG between meals, or even more frequently during the night. Have you had any issues with low BG or hypoglycemia?

I noticed in the prescribing information of the Seroquel, that one of the possible BG related side effects is diabetic ketoacidosis. These are ketones which are produced when BG is very high AND insulin levels are low. Ketoacidosis is seldom seen in type 2 diabetics because they often have high levels of insulin combined with high BG, because they are resistant to insulin. So it would seem possible you may be short of insulin. Have you experienced any signs of ketoacidosis? Fruity alcohol like smell on the breath? To follow this possibility up with your doctor I would ask for a C-Peptide test. It indicates your level of insulin. If for example you have a fasting BG of 190 (quite high), and a low C-Peptide, this indicates your high BG is from lack of insulin, similar to a type 1 diabetic. If this is the case, the metformin is likely not doing you much good, but the glyburide should.

I see you have a few choices to discuss with your doctor:

1. Shotgun approach - Increase the dose of current treatment. It may get you by for a bit longer. If you go that route I would discuss changing the glyburide for Prandin. Prandin also stimulates insulin, but only acts for about 2 hours, and you can take higher doses without experiencing lows.

2. Get a better handle on what the problem is - C-Peptide test to determine if you are short of insulin. If you are then more glyburide or better still Prandin could do the trick, at least for a while.

3. If you are a slow developing type 1 - short of insulin, then sooner or later you will likely need insulin. And if shortage of insulin is the problem, starting insulin will bring dramatic results.

Just my thoughts, and obviously you need to discuss with your doctor,

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dianewms replied on Wed, Jul 22 2009 1:39 PM

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thank you for your input.  It helps me make an informed decision.  I did get a message on my meter that said check your ketones.  My feeling is that they will put me on once a day insulin on Monday and maybe I would be relieved.  I see the big numbers and I freak out and my anxiety levels go through the roof.  I have been on the verge of a panic attack today so maybe getting the dramatic results quickly would help that as well.  I also have a call into my osychiatrist to let him know I would consider a change from the seroquel although I dont really want to get off it.  I dont know how people get through this without help from people like you who have been through it.  thank you for being my light.

Diane

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Spirit replied on Wed, Jul 22 2009 6:23 PM

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Diane:  Ron gave you some very good jumping off points for a discussion with your doctor.

My slant is slightly different. Diet, exercise, oral meds and insulin are simply tools we use to manage our diabetes.  The important thing is that we DO manage it, not what tools we use.  We just have to use the tools that are best suited for the job.  Failure is not using the correct tool.  Success is getting the bg numbers under control.  Focus on the results, not the method. And as you see improved results, your anxiety should decrease, which would be a good thing!

Spirit

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Ron AKA replied on Thu, Jul 23 2009 12:54 AM

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dianewms:

thank you for your input.  It helps me make an informed decision.  I did get a message on my meter that said check your ketones.  My feeling is that they will put me on once a day insulin on Monday and maybe I would be relieved.  I see the big numbers and I freak out and my anxiety levels go through the roof.  I have been on the verge of a panic attack today so maybe getting the dramatic results quickly would help that as well.  I also have a call into my osychiatrist to let him know I would consider a change from the seroquel although I dont really want to get off it.  I dont know how people get through this without help from people like you who have been through it.  thank you for being my light.

I don't think your meter is really smart enough to know if you have ketones or not. It is probably just "speculating" based on the BG number. I do recall that there are some tests for ketones (urine strip???). Perhaps some type 1's with experience could comment.

Once a day insulin is not a bad idea. If nothing else it will give you some idea if you are short of insulin or not (a C-Peptide test is a better way though). I like to see my A1C under 6.0 instead of the often recommended 7.0, so I take insulin once a day at bedtime. The Levemir really helps in keeping my morning BG below 100 which is my target. I could easily keep BG fasting under 126 without it, but my feeling is that long term complications of diabetes are more likely prevented by keeping it lower than the diagnosis limit for diabetes.

Don't know if your concern is a worry that taking insulin is admitting defeat or about the potential pain of injections. On the former, I don't see it as defeat at all, but a realization that BG control is very important, and one has to use every tool in the box to make it happen. I often think about the work of Banting and Best (Proud they were Canadians!), and it brings a tear to my eye on how many lives they have saved. On the pain thing, I distinctly recall the first time I used my BG meter. My hands were shaking, and after I did it, I thought "that is no big deal". Same with the insulin injections. I use a pen with a Novofine 32G 6mm needle. Have to admit that 95% of the time I feel nothing. On the other 5% it is no worse than the lancet stick for a BG test.

Hope that helps some, and if there are any questions just ask. I am a firm believer that you have to visit your doctor well informed and with a list of questions to ensure they are really getting to the root of the problem an our concerns as a patient.

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dianewms replied on Fri, Jul 31 2009 4:27 PM

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SUCESS!  I finally reached a good combination of drugs after about 6 months of trying.  Im on 750 metformin twice a day.  2.5 glyburide in the AM and 10 units of levamir before bed.  My sugar is very consistant with this combo as long as I eat appropriately.  Thank you all for your support.  I went into a real depressive period trying to get it right.  Im a very concientious person and I felt like a failure.  Now for the weight loss.  It is so hard to eat what I am supposed to and lose weight.

Diane

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Spirit replied on Fri, Jul 31 2009 5:06 PM

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Diane:  I am so glad that you have found the right combo of meds to manage your diabetes.  It can take a while and can be pretty discouraging until the correct treatment plan is worked out.  Good for you for persisting.

You may find that weight loss is a tad easier with bg under better control.  With your body utilizing glucose more efficiently and if you exercise regularly your body's metabolism should be revved up a bit, making weight loss more likely.  Keep us posted.

Spirit

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Ron AKA replied on Fri, Jul 31 2009 7:29 PM

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Good to hear things have turned around. The one thing you have to watch with the Glyburide is low BG either right before meals or in the middle of the night. I hated doing it, but it would be worthwhile setting your alarm for 3:00 AM or so to test and make sure you are not going low. The combination of Levemir and Glyburide would make lows a possibility in particular during the night.

I'm not a believer in the theory that insulin causes weight gain, but there is an association with insulin and weight gain. My view is that too much food and/or too little exercise causes weight gain. The rub with insulin and insulin stimulating drugs like Glyburide, is when you are forced to eat to avoid going low. The snacks you may take to avoid the between meal and overnight lows can add up, unless you are very careful in subtracting those calories from your regular meal. Perhaps it is only a thing in my head, but I always associate a low BG with starvation and being short of food. True one MUST consume carbs to get BG back up, but in the total for the day, one may be far from starving, and overeating.

Just my thoughts, and glad to see BG is back on track.

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nance replied on Sun, Aug 2 2009 11:29 PM

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dianewms:

.......Now for the weight loss.  It is so hard to eat what I am supposed to and lose weight.

 

Hi, Diane!  Are you trying to do it with just food, or are you also able to use exercise?  (I was going to ask that question the other day regarding your blood sugar control, but never got around to it.)  I think controlling blood sugar with just food alone and controlling weight with just food alone would be really hard.  Like Spirit said -- exercise gets the metabolism going and helps keep both blood sugar and weight where they belong, but often doctors neglect to mention it, throwing the focus only on the fuel.  I was sometimes able to lose weight through the years, but all of it would eventually come right back, and usually very soon, too.  It wasn't until I started exercising between meals every day to control blood sugar that I was able to lose all 40 excess pounds which had crept up on me over the years.  It started melting off right away, and was all gone within 6 months.  I kept on exercising for blood sugar control, and it has helped keep my weight close to normal for the last 11 years.  Okay -- I read back through the posts and saw where you're walking regularly, and that helped you lose 20 pounds so far.   Good work!  The thing is, if you've been doing the walking for a while, you may need to turn the exercise up a notch in order to keep up with your increased fitness level and keep heart rate up enough to keep metabolism boosted enough to keep blood sugar and weight down in a good range.  That's the situation that I ran into, anyway.