Need help navigating life with diabetes? You can always Ask D'Mine! Welcome again to our weekly Q&A column, hosted by veteran type 1, diabetes author and educator Wil Dubois. This week, Wil offers some (non-doctor) thoughts on mixing and matching your diabetes meds.
Dan, type 1 from California, writes: Since type 1 diabetics are constantly dealing all their lives with the issue of glucose release after meals, at night, and whenever from our livers, why aren't we given metformin to control this process as a standard of care? Why is it that metformin is only given to type 2 diabetics when type 1s are dealing with the same issue—a liver that likes to dump glucose (that is, diabetes screws up the hormonal system that naturally communicates to the liver about when to dump glucose and when not to). Why is it that conventional wisdom dictates that insulin is enough to ensure the liver is regulated for type 1 diabetics when it clearly is not (it helps but does not effectively control glucose release)?
Wil@Ask D'Mine answers: Ya' got me. Metformin isn't FDA approved for us T1s, but probably only because no one wants to pay for the studies on a generic medication. Where's the profit in that? Of course, a med can become part of a treatment standard even without an FDA indication; there's precedent for that—even with metformin. It's used "off-label" to treat polycystic ovary syndrome and is included in the standard of care treatment guidelines of the American College of Obstetricians and Gynecologists. That said, I can't think of a single case when one of the diabetes standards (usually ADA or AACE in our country) ever included off-label use of a med. Maybe the diabetes docs who developed the standards were all boy scouts when they were younger. Or maybe, given the lack of studies, they didn't feel there was enough evidence to recommend it.
Note that there's been more research happening of late on metformin use in type 1s. Just this month there's an article in the ADA journal Diabetes Care about this. And late last year, we heard the JDRF was funding a study on this idea.
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And for what it's worth, beyond standards, a great number of type 1s are prescribed metformin off-label by their docs, who are apparently going off the reservation and doing what they think is the right thing to do, standards be damned. Of course, it's more commonly being given to our kind for weight loss than for hepatic glucose control.
Still, you are right that, on the surface at least, it makes sense.
Metformin addresses the physiological defects common to the two types of diabetes, and it plays just fine with insulin. The only reason I can think of why it might be viewed as a bad idea in our kind is that metformin is processed by the kidneys and the drug can be kind of rough on them. But that said, whether we or our type 2 cousins have collectively worse kidneys is up for grabs. And either way, you can test kidney function and stop the met if things are getting dicey. Oh, and I honestly don't know, but met might hold back the liver's release of glucagon in really bad lows. Still, plenty of type 2s take metformin and both basal and fast insulin, and no one is nattering on about stopping their met, so this probably isn't an issue either.
And you are right again that getting the liver to shut off at meals is a real problem, and one that insulin isn't of any particular use for. Personally, I like Victoza for this purpose. It curbs my meal time excursions a great deal, which I attribute to its ability to temporarily shut off the liver at meal times. I also like the fact that it acts in a glucose-dependent manner, so it's not working when I don't need it to. Plus, to be honest, I prefer shots to pills. But that's just me.
Actually, it would be interesting to know how many type 1s actually do use metformin. How about an informal poll via comments? Any of you T1 Metfers (debut vocabulary word for people who take metformin) want to let us know what you are experiencing?
Carmen, type 2 from Canada, writes: I've had diabetes for over 21 years now and have had it in control most of that time with exercise, food, etc., until recently. I was prescribed Tradjenta 5 mg tablet one a day along with 2,000 Metformin which I have been taking for the last 10 years, and Novomix, 38 units twice a day. But my sugar readings have gone up a lot over the last few months. I live in Ottawa, Ontario, Canada. It's my American cousin who referred me to your site - can you help? I'm desperate - The specialist I had for diabetes closed my file because I knew how to control it, and my GP has not enough information on what I am looking for.So that's why I am asking the question: Should I increase the Tradjenta or increase the Novomix?
Wil@Ask D'Mine answers: I'm not licensed to give medical advice, but I can tell you that you are taking the maximum dose of Tradjenta and that taking more than the max dose of any pill is dangerous.
Insulin, on the other hand, has no maximum. You take what you need to get the job done, and most diabetes patients are educated in how to self-adjust their dosing as needed.
The mix insulin you use has both a basal, or foundation, and a fast-acting insulin mixed together. You need to get the basal high enough to curb your fasting sugars without taking so much that the fast part makes you go low. Small increases every day, with careful monitoring of the results, is the safest way to do this.
Hope that helps, but in the meantime, call the stupid specialist back and tell him to reopen your file. For God's sake, we never "close the file" on this lifelong disease, do we?
This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.