There's no end in sight when you have diabetes — but is there ever a time when it's right to quit your meds? In this edition of our weekly diabetes advice column, Ask D'Mine, a couple of our readers are wondering if their meds are no longer so good...

As per usual, we've got some info-packed responses from host Wil Dubois, diabetes author and community educator and also a veteran type 1 himself.

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Karl from New Hampshire, type 1,writes: Victoza has stopped working its magic on my appetite, so my doc and I have decided I should stop taking it.  Though now that I'm of it, I'm eating more, feel fat as hell, and am second guessing my decision to stop.  Your thoughts would be welcome.  The doc also started me on Metformin, which I seem to be tolerating OK. But I don't know much about it, or how it works, or what I should expect. 

Wil@Ask D'Mine answers: Most people who start Victoza find their appetite becomes petite. The problem is, you can't buy a petite fries at the drive-through. A little at a time, the monstrous portions of food we are offered erodes the effectiveness of Victoza as we cave a little at a time to our culture of eat-eat-eat. You can end up overcoming and overwhelming the appetite-reducing effect of Victoza one bite at a time, to the point where you might question if it's doing you any good at all. But as you've discovered, once you stop it, you find it was still doing more good than you realized. In fact, many people who drop Victoza find that suddenly they have bigger appetites than they did pre-Victoza. It's like the effect has been reversed with compound interest due.

So, has big Pharma finally created the perfect slave drug that you can't stop taking? No, Victoza is just one of those drugs that shouldn't be stopped cold-turkey, that's all. Thirty days hath September, April, June, and November... and your Victoza pen actually has thirty clicks. The official doses are at 0.6 mg, 1.2 mg, and 1.8 mg; but all those in-between clicks are legitimate in-between doses, too. You can taper yourself off from the full dose one click at a time over a thirty-day period. That'll give your body time to adapt slowly to the change, and, if you'll pardon the pun, you'll give your system a chance to take a bite out of the appetite increase that comes from stopping Victoza.

Reminder: Our April '10 Victoza post has become the internet's unofficial chat board for all things Victoza with over 1,000 comments to date!

Now as to the metformin, use of met in type 1s is strictly "off label," meaning that the drug is not FDA approved for our kind. But come to think of it, use of Victoza in a type 1 is off label, too. You are so off the label you're almost off the grid! Anyway, metformin is a cheap, time-tested blood sugar-lowering pill that has been in clinical use for over 50 years. It's now the starting gate drug for type 2 diabetes worldwide, having been embraced as the standard of care by the ADA, the AACE/ACE, and the IDF.

It lowers blood glucose levels in type 2s in several ways: it keeps the liver from dripping too much sugar into the blood stream overnight, it helps with carbohydrate absorption, and it is a mild insulin sensitizer. As an unexpected dividend, it can cause mild weight loss and may help the heart, too. On the down side, it tends to cause nausea and diarrhea when you start it (the extended release version seems to give people less trouble in this regard). Start small, at 500 mg at night for a week or two, and increase to whatever dose your doc wants slowly over a month or so. Most people need 2,000 mg a day. Now, metformin is a really bad idea in anyone who has a funky liver as liver issues + metformin = higher risk for a generally fatal side effect called . So it shouldn't be used by alcoholics and folks with hepatitis. Met also shouldn't be used in folks with bad kidneys, as the med is cleared from the body by the kidneys and if your kidneys aren't up to snuff, a toxic level of metformin can buildup in your body.

I should mention that the use of metformin in types 1s used to be very controversial, but it does seem effective, as least as far as requirements goes, and it's becoming more and more commonly used in T1s over the last few years. Our own Allison writes about her experience with metformin here.

The latest review of studies I could find show that for a fat as hell T1 (hey, your words, not mine!), adding metformin can shave seven or so units off your total daily dose of insulin, knock a half-point off your A1C, and help you to lose maybe a dozen pounds. You might also improve your cholesterol, too. Not bad for a four-dollar-a-month drug!

Test more often, though, Karl. Met with insulin will up your hypo risk quite a bit.

Celina from Texas, type 1,writes: I am starting to plan my first pregnancy with my husband. I use Lantus and Humalog. I would like to know if these insulins can also be used during pregnancy and if they are safe for the baby. If the answer is no, could you please let me know what is the recommended insulin for a type 1 diabetic mom during and after pregnancy?

Wil@Ask D'Mine answers: No worries. Your insulin is fine for your future papoose. All the currently available insulins are considered safe, all being in either pregnancy category B or C. The older school insulins like Novolin, Humulin, and NPH all carry the theoretically superior "B" rating, as does the newer Novolog; while the rest of the modern pack (Lantus, Humalog, Apidra) all carry the "C" rating.

I should point out that the well-intended pregnancy categories have ended up causing no end of confusion and worry among moms-to-be. They aren't a measure of relative risk; they're a rating system for the strength of clinical studies of various meds in pregnant women. Not surprisingly, of course, most medications haven't been studied in clinical settings on pregnant women. What this means is that while most meds carry the category C rating, they're not necessarily more dangerous than a category B—it's just that they're less studied.

Of course, as a type 1 you have little choice. No insulin, no momma. No momma, no baby. But even for women with gestational diabetes, insulin is often the first choice of many docs on point for the care of the women and their passengers, even over the theoretically safer category B oral pills like glyburide and metformin.

Why? Because insulin can't cross the placenta in significant amounts. That's good news for the baby. Insulin is also infinitely scalable, so BG control can be fine-tuned better with insulin than it can be with pills. And, although I'm sure it happened at least once in history, I don't know of any doctor that has moved a PWD from newer insulin to older insulin because of the theoretical improved safety between the two categories.

That's because, frankly, the newer insulins are much better at controlling blood sugar than the older ones. And while we may be lacking the properly sealed, certified, randomized study needed to move Lantus from C to B, we have very clear evidence on the effects of elevated blood sugar on babies in the womb. That's why the glycemic targets for pregnant women are so stringent—now at 95 mg/dL or less fasting for gestational diabetes—with 140 max at one hour post-meals, and 120 max at two hours after meals; and even lower targets for pregnant women with pre-existing diabetes.

So for you, Celina, the ADA's standards for this year call for fasting BG between 60-99 and peak readings after meals at 129. It's gonna be tough to get those kinds of numbers, but it's only for nine months. And hey, on the way home from the hospital you can always stop at Krispy Kreme and make up for lost time.

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.