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Thursday, February 19, 2009
The Symlin Pen
The FDA approved pre-filled Symlin pens in November of 2007 and Amylin made them available in January of 2008. Previously, it was only available in vials. There are currently two pens available: the SymlinPen 60 and 120. The SymlinPen 60 delivers 15, 30, 45, or 60 micrograms per dose. The SymlinPen 120 delivers 60 or 120 micrograms per dose. Both may be stored at room temperature, up to 86 degrees, after first use.
Symlin, An Injectable Form of Amylin
During the destruction of beta cells in Type 1 or Type 1.5 diabetes by friendly fire from antibodies, the body actually loses two hormones. And similar to insulin, Amylin production may fall in Type 2 diabetes over time. Amylin is normally co-secreted alongside insulin and, like insulin, is released by the beta cells around the clock with larger amounts released at mealtimes.
Insulin was the first of the two hormones to be discovered because it was so critical to survival. It was not until 1970 that amylin was discovered, and not until the early 1990s is that its role began to be understood. Not essential for life, amylin plays an important role in glucose regulation by slowing digestion and suppressing an excessive release of glucagon that is seen after meals in Type 1 diabetes. The excess glucagon rise seen in Type 1 diabetes causes additional glucose release by the liver at mealtimes. The release of amylin at mealtimes minimizes the glucose spikes that are often seen in Type 1 diabetes after meals.
Symlin is a modified longer-acting form of amylin that was released by the FDA in 2005. This prescription medication dramatically improves post meal glucose control and reduces glucose variability and glucose exposure in anyone whose insulin production is limited. Symlin decreases glucagon secretion, decreases appetite, and delays gastric emptying. When injected before meals, post meal blood sugars become easier to control. Users often comment that they feel better with more stable glucose readings.
One caution when starting on Symlin is that it can cause severe low blood sugars if meal insulin doses are not lowered on the day it is started and for at least the first few days of use. If meal insulin doses are not reduced, up to 30% of users experience severe hypoglycemia within about 3 hours of eating. To reduce the risk of hypoglycemia, Symlin is started at very small doses and then gradually increased every few days until the desired effect is seen. Meal insulin doses are typically reduced by 30% to 50% when starting and later adjusted based on pre and post meal glucose results once a final Symlin dose is reached. Long-acting insulin doses or basal rates may also need to be lowered, especially if these make up more then 50% of the starting TDD (total daily dose of insulin). As weight loss occurs in someone who is overweight, additional insulin reductions will be needed over time.
Dosing
Symlin is injected with a standard insulin syringe, so dosing is flexible. How much to use depends on what it is used for. For weight loss, maximum doses are usually best, while lower doses often work when the goal is to normalize post-meal glucose levels. The manufacturer recommends starting with 2.5 units and increasing to 5 units, then 7.5 units, and 10 units before each meal if no nausea is encountered for three days.
However, different people will require very different doses and we recommend that Symlin doses be individualized in the same way as insulin doses. If your goal is to reduce post meal spiking and glucose variability, raise the Symlin dose by one unit every three days until you reach a dose where most of your post meal blood sugar readings rise no more than 40 to 60 mg/dl (2.2 to 3.3 mmol) above where they started. The idea is to take enough to have good post meal control (less variability) without overly delaying the normal rise in glucose after a meal (less problem correcting a low reading). Keep raising the Symlin or increasing meal boluses until post meal readings are consistently less than 60 mg/dl (3.3 mmol) higher than the premeal readings. The correct doses of Symlin and insulin allow you to keep most post meal readings from rising much while causing few lows. In many Type 1s, only 2 to 6 units taken two or three times a day before meals are required to do this. Symlin is usually taken just before meals that contain at least 250 calories or 30 grams of carbohydrate. If a dose is missed, wait until the next meal to take the regular scheduled dose.
Your current TDD for insulin can guide your premeal Symlin dose. Approximately 10% of your insulin TDD is needed as Symlin before each meal. For instance, if you use 40 units of insulin a day you will need approximately 4 units of Symlin before each meal to control your post meal readings. For weight loss, of course, larger amounts will be needed. A safer way to increase Symlin is to start with 2 units before two or three meals a day, or 1 unit if your TDD is less than 30 units of insulin a day. Increase by 1 unit per meal every three days as long as nausea is not present.
Post meal Control
Glucose spiking after meals can be totally eliminated at higher doses, with flat glucose trend lines often seen on a continuous monitor. At higher Symlin doses, however, if a large carb meal is consumed, the rise in the blood sugar may not be seen until several hours later, such as a high reading at breakfast the next morning after a large carb intake at dinner. Matching injected insulin doses to Symlin can be difficult. Today's rapid insulins become too fast when larger doses of Symlin are used. If you inject your insulin, the use of a slower insulin like Regular may be preferred.
On a pump, a combo bolus (some now, the rest over time) or an extended bolus can be used to match the slower rise in glucose after meals. If a blood sugar is low before a meal, raise it before taking Symlin. Reduce the meal bolus and give it as an extended bolus. If Symlin doses are missed for more than two or three days, do not restart with full doses. Instead, restart at a lower dose and build up to lessen the risk of hypoglycemia.
Weight Loss
Less hunger allows some people who are overweight to lose significant amounts of weight, while normal weight individuals lose none. Symlin is currently undergoing studies for approval by the FDA as a weight loss drug.
For weight loss, the dose may occasionally need to go higher.
Stability
Symlin is less stable than insulin. If one bottle of Symlin appears to have no effect on your blood sugar try another bottle. Symlin activity is more vulnerable to time and temperature than insulin and can lose significant activity, especially if a sample bottle was handed out from a physician's office. If you seem to get little effect from a bottle, start a fresh bottle at a lower dose. Excess doses are easy to spot by a feeling of fullness or nausea after the dose is given. Vomiting and diarrhea may occur on an excessive dose. If side effects occur, simply lower the dose by one or 2 units. Increase the dose again after there is no fullness or nausea for at least three days.
Tips On Handling Lows
Symlin delays the digestion of all food, including the carbs you use to raise a low blood sugar. If a low occurs, use glucose tablets if available and chew them as long as possible to allow more glucose to be absorbed directly into the bloodstream. Be patient, as the rise in your glucose will be slowed because of Symlin. Likewise when lowering a high reading with insulin, it will take longer and may require larger than normal insulin doses because food is still being absorbed.
Insulin was the first of the two hormones to be discovered because it was so critical to survival. It was not until 1970 that amylin was discovered, and not until the early 1990s is that its role began to be understood. Not essential for life, amylin plays an important role in glucose regulation by slowing digestion and suppressing an excessive release of glucagon that is seen after meals in Type 1 diabetes. The excess glucagon rise seen in Type 1 diabetes causes additional glucose release by the liver at mealtimes. The release of amylin at mealtimes minimizes the glucose spikes that are often seen in Type 1 diabetes after meals.
Symlin is a modified longer-acting form of amylin that was released by the FDA in 2005. This prescription medication dramatically improves post meal glucose control and reduces glucose variability and glucose exposure in anyone whose insulin production is limited. Symlin decreases glucagon secretion, decreases appetite, and delays gastric emptying. When injected before meals, post meal blood sugars become easier to control. Users often comment that they feel better with more stable glucose readings.
One caution when starting on Symlin is that it can cause severe low blood sugars if meal insulin doses are not lowered on the day it is started and for at least the first few days of use. If meal insulin doses are not reduced, up to 30% of users experience severe hypoglycemia within about 3 hours of eating. To reduce the risk of hypoglycemia, Symlin is started at very small doses and then gradually increased every few days until the desired effect is seen. Meal insulin doses are typically reduced by 30% to 50% when starting and later adjusted based on pre and post meal glucose results once a final Symlin dose is reached. Long-acting insulin doses or basal rates may also need to be lowered, especially if these make up more then 50% of the starting TDD (total daily dose of insulin). As weight loss occurs in someone who is overweight, additional insulin reductions will be needed over time.
Dosing
Symlin is injected with a standard insulin syringe, so dosing is flexible. How much to use depends on what it is used for. For weight loss, maximum doses are usually best, while lower doses often work when the goal is to normalize post-meal glucose levels. The manufacturer recommends starting with 2.5 units and increasing to 5 units, then 7.5 units, and 10 units before each meal if no nausea is encountered for three days.
However, different people will require very different doses and we recommend that Symlin doses be individualized in the same way as insulin doses. If your goal is to reduce post meal spiking and glucose variability, raise the Symlin dose by one unit every three days until you reach a dose where most of your post meal blood sugar readings rise no more than 40 to 60 mg/dl (2.2 to 3.3 mmol) above where they started. The idea is to take enough to have good post meal control (less variability) without overly delaying the normal rise in glucose after a meal (less problem correcting a low reading). Keep raising the Symlin or increasing meal boluses until post meal readings are consistently less than 60 mg/dl (3.3 mmol) higher than the premeal readings. The correct doses of Symlin and insulin allow you to keep most post meal readings from rising much while causing few lows. In many Type 1s, only 2 to 6 units taken two or three times a day before meals are required to do this. Symlin is usually taken just before meals that contain at least 250 calories or 30 grams of carbohydrate. If a dose is missed, wait until the next meal to take the regular scheduled dose.
Your current TDD for insulin can guide your premeal Symlin dose. Approximately 10% of your insulin TDD is needed as Symlin before each meal. For instance, if you use 40 units of insulin a day you will need approximately 4 units of Symlin before each meal to control your post meal readings. For weight loss, of course, larger amounts will be needed. A safer way to increase Symlin is to start with 2 units before two or three meals a day, or 1 unit if your TDD is less than 30 units of insulin a day. Increase by 1 unit per meal every three days as long as nausea is not present.
Post meal Control
Glucose spiking after meals can be totally eliminated at higher doses, with flat glucose trend lines often seen on a continuous monitor. At higher Symlin doses, however, if a large carb meal is consumed, the rise in the blood sugar may not be seen until several hours later, such as a high reading at breakfast the next morning after a large carb intake at dinner. Matching injected insulin doses to Symlin can be difficult. Today's rapid insulins become too fast when larger doses of Symlin are used. If you inject your insulin, the use of a slower insulin like Regular may be preferred.
On a pump, a combo bolus (some now, the rest over time) or an extended bolus can be used to match the slower rise in glucose after meals. If a blood sugar is low before a meal, raise it before taking Symlin. Reduce the meal bolus and give it as an extended bolus. If Symlin doses are missed for more than two or three days, do not restart with full doses. Instead, restart at a lower dose and build up to lessen the risk of hypoglycemia.
Weight Loss
Less hunger allows some people who are overweight to lose significant amounts of weight, while normal weight individuals lose none. Symlin is currently undergoing studies for approval by the FDA as a weight loss drug.
For weight loss, the dose may occasionally need to go higher.
Stability
Symlin is less stable than insulin. If one bottle of Symlin appears to have no effect on your blood sugar try another bottle. Symlin activity is more vulnerable to time and temperature than insulin and can lose significant activity, especially if a sample bottle was handed out from a physician's office. If you seem to get little effect from a bottle, start a fresh bottle at a lower dose. Excess doses are easy to spot by a feeling of fullness or nausea after the dose is given. Vomiting and diarrhea may occur on an excessive dose. If side effects occur, simply lower the dose by one or 2 units. Increase the dose again after there is no fullness or nausea for at least three days.
Tips On Handling Lows
Symlin delays the digestion of all food, including the carbs you use to raise a low blood sugar. If a low occurs, use glucose tablets if available and chew them as long as possible to allow more glucose to be absorbed directly into the bloodstream. Be patient, as the rise in your glucose will be slowed because of Symlin. Likewise when lowering a high reading with insulin, it will take longer and may require larger than normal insulin doses because food is still being absorbed.
Lantus
Lantus® (insulin glargine [rDNA origin] injection) is a new true once a day background insulin from Aventis Pharmaceuticals. It represents a remarkable breakthrough in that it is the first insulin to offer truly flat insulin levels through the entire day for most users. It can be used by people with Type 1 or Type 2 diabetes who are six years old or older. Considered an alternative to an insulin pump, it is the first long-term insulin that has a predictable and consistent insulin activity.
Tips For Starting
Morning or night? Aventis recommends taking Lantus at bedtime. Lantus' actual duration of action is 18 to 26 hours. Although the timing varies from indiviual to individual, it appears to be consistent in the same indiviual. The advantage to bedtime dosing is that for most people any gap in Lantus' activity would happen after dinner and this gap could be covered with a little extra Humalog or Novolog in the dinner injection.
Whether you take it at bedtime or breakfast, it helps to be consistent about timing, so pick a time when you will remember to take the injection at the same time each day.
A good way to eliminate any gaps in insulin delivery, whether caused by a duration of action less than 24 hours or by erratic timing of injections is to split the Lantus dose equally into 2 injections a day given at breakfast and at dinner or bedtime. This smoothes out the sometimes erratic insulin levels that may occur with once a day dosing.
Lantus is a clear insulin which is unlike other long-acting insulins (Lente, NPH, Ultralente) that are all cloudy. Although the bottles have a different shape, some users have already injected a bedtime dose of Humalog rather than Lantus! Be very careful not to confuse Lantus with Humalog and other clear insulins.
DO NOT MIX Lantus with any other insulin. Do not even reuse a syringe in Lantus that has come in contact with another insulin.
Lantus becomes inactivated if it comes in contact with even small amounts of other insulins. This makes it appear hazy. Never use any Lantus that is not crystal clear.
Lantus cannot replace the need for Humalog or another fast insulin to cover carbs in meals. However, occasionally in people with Type 2 diabetes, when the before breakfast blood sugar is normalized with Lantus, a premeal medication like Starlix, Prandin, or even Precose may be able to control the post meal blood sugars.
How Do I Know When I'm On The Right Dose?
One really nice feature of Lantus is that it makes finding the correct dose easy. Because of its very stable 24 hour action, the dose is gradually increased until the fasting or before breakfast blood sugar has been normalized. If low blood sugars occur during the night and they are not being caused by a dose of fast acting insulin taken during the evening hours, the dose of Lantus would be gradually reduced until the lows stop.
Similar to the basal rate of an insulin pump, the Lantus dose can be checked by skipping a meal during the day, but the real test for whether the dose is accurate comes from stable, flat overnight blood sugars.
Once the Lantus dose has been determined, the doses of premeal Humalog, Novalog, Starlix, etc. would then be adjusted to keep postmeal blood sugars normal. With a stable background insulin, carb counting becomes especially helpful as a way to decide on the insulin dose before each meal.
How Lantus Works
This insulin analog was designed to have low solubility in water at a neutral pH, such as that found in body fluids and other insulins. Lantus becomes completely soluble only at an acid pH of 4. Once this is injected under the skin, the acidic solution is neutralized leading to the formation of microprecipitates. The microprecipitates allow small amounts of insulin to be released slowly, resulting in a relatively constant concentration/time profile over 22 hours +/- 4 hours with no pronounced peak in activity.
Lantus was modified to allow this precise action. Normal insulin has two protein chains called A and B that have two zinc crosslinks between them. Lantus differs from other insulins in that one asparagine at position A21 of the A chain is replaced by glycine, and two arginines have been added added to one end of the B-chain.
Cautions
Occasionally, the acidic nature of this insulin may cause mild discomfort at the injection site in some individuals. This does not appear serious enough to cause users to discontinue the insulin.
Like Humalog, Lantus is structurally different from human insulin, but it appears to rarely cause an immune or allergic response. Like any insulin allergy, the response can range from a mild local itching to a severe allergic reaction with swelling of the tongue, inability to breath and shock or death if rapid treatment is not found.
Lantus should be used with great caution and only under the supervision of a physician during pregnancy or prior to pregnancy.
How Often Does Lantus Fail To Work?
How many people fail to respond to Lantus is unknown. The vast majority of users get a consistent action from this insulin every day. However, Aventis' clinical studies did pick up some individuals who had marked differences in the action time for Lantus from one day to the next. In rare individuals, it's action time was as short as 11 hours, but it is unknown why this difference occurs.
Lantus may not work for everyone, but for the vast majority who are willing to take an extra injection or two a day in order to get terrific control, this insulin is definitely worth a try.
Tips For Starting
Morning or night? Aventis recommends taking Lantus at bedtime. Lantus' actual duration of action is 18 to 26 hours. Although the timing varies from indiviual to individual, it appears to be consistent in the same indiviual. The advantage to bedtime dosing is that for most people any gap in Lantus' activity would happen after dinner and this gap could be covered with a little extra Humalog or Novolog in the dinner injection.
Whether you take it at bedtime or breakfast, it helps to be consistent about timing, so pick a time when you will remember to take the injection at the same time each day.
A good way to eliminate any gaps in insulin delivery, whether caused by a duration of action less than 24 hours or by erratic timing of injections is to split the Lantus dose equally into 2 injections a day given at breakfast and at dinner or bedtime. This smoothes out the sometimes erratic insulin levels that may occur with once a day dosing.
Lantus is a clear insulin which is unlike other long-acting insulins (Lente, NPH, Ultralente) that are all cloudy. Although the bottles have a different shape, some users have already injected a bedtime dose of Humalog rather than Lantus! Be very careful not to confuse Lantus with Humalog and other clear insulins.
DO NOT MIX Lantus with any other insulin. Do not even reuse a syringe in Lantus that has come in contact with another insulin.
Lantus becomes inactivated if it comes in contact with even small amounts of other insulins. This makes it appear hazy. Never use any Lantus that is not crystal clear.
Lantus cannot replace the need for Humalog or another fast insulin to cover carbs in meals. However, occasionally in people with Type 2 diabetes, when the before breakfast blood sugar is normalized with Lantus, a premeal medication like Starlix, Prandin, or even Precose may be able to control the post meal blood sugars.
How Do I Know When I'm On The Right Dose?
One really nice feature of Lantus is that it makes finding the correct dose easy. Because of its very stable 24 hour action, the dose is gradually increased until the fasting or before breakfast blood sugar has been normalized. If low blood sugars occur during the night and they are not being caused by a dose of fast acting insulin taken during the evening hours, the dose of Lantus would be gradually reduced until the lows stop.
Similar to the basal rate of an insulin pump, the Lantus dose can be checked by skipping a meal during the day, but the real test for whether the dose is accurate comes from stable, flat overnight blood sugars.
Once the Lantus dose has been determined, the doses of premeal Humalog, Novalog, Starlix, etc. would then be adjusted to keep postmeal blood sugars normal. With a stable background insulin, carb counting becomes especially helpful as a way to decide on the insulin dose before each meal.
How Lantus Works
This insulin analog was designed to have low solubility in water at a neutral pH, such as that found in body fluids and other insulins. Lantus becomes completely soluble only at an acid pH of 4. Once this is injected under the skin, the acidic solution is neutralized leading to the formation of microprecipitates. The microprecipitates allow small amounts of insulin to be released slowly, resulting in a relatively constant concentration/time profile over 22 hours +/- 4 hours with no pronounced peak in activity.
Lantus was modified to allow this precise action. Normal insulin has two protein chains called A and B that have two zinc crosslinks between them. Lantus differs from other insulins in that one asparagine at position A21 of the A chain is replaced by glycine, and two arginines have been added added to one end of the B-chain.
Cautions
Occasionally, the acidic nature of this insulin may cause mild discomfort at the injection site in some individuals. This does not appear serious enough to cause users to discontinue the insulin.
Like Humalog, Lantus is structurally different from human insulin, but it appears to rarely cause an immune or allergic response. Like any insulin allergy, the response can range from a mild local itching to a severe allergic reaction with swelling of the tongue, inability to breath and shock or death if rapid treatment is not found.
Lantus should be used with great caution and only under the supervision of a physician during pregnancy or prior to pregnancy.
How Often Does Lantus Fail To Work?
How many people fail to respond to Lantus is unknown. The vast majority of users get a consistent action from this insulin every day. However, Aventis' clinical studies did pick up some individuals who had marked differences in the action time for Lantus from one day to the next. In rare individuals, it's action time was as short as 11 hours, but it is unknown why this difference occurs.
Lantus may not work for everyone, but for the vast majority who are willing to take an extra injection or two a day in order to get terrific control, this insulin is definitely worth a try.
Lilac plant
Metformin is a chemical kin to the French lilac plant, which was noted in the early 1900’s to lower the blood sugar. However, French lilac, like phenformin, turned out to be too toxic for use in humans. Metformin, with a much shorter action time than phenformin, has a much lower risk for severe side effects and is quite safe for use by anyone who is otherwise healthy. In fact, in the major UKPDS study, it was the only drug that reduced diabetes-related death rates, heart attacks, and strokes. It should not be used by those who use more than two ounces or two drinks of alcohol a day, who have congestive heart failure, or who have significant kidney, liver, or lung disease.
Metformin lowers fasting blood glucose levels by an average of 25% (17 to 37%), postprandial blood glucose up to 44.5%, and the A1c by an average of 1.5% (0.8 to 3.1%). Metformin reduces raised plasma insulin levels in cases of metabolic syndrome by as much as 30% and reduces the need for injected insulin in Type 2s by 15 to 32%.
Metformin is available under the trade name Glucophage, or as an extended-release tablet called Glucophage XR. It works well when combined with sulfonylureas. A combination of glyburide and metformin is available as Glucovance. Combined therapy leads to a greater reduction in blood sugar than can be attained by either class alone. Generic metformin is available at a reduced cost.
Metformin possesses some distinct advantages in treating diabetes. Excess glucose produced by the liver is the major source of high blood sugars in Type 2 diabetes and is typically the reason for high blood sugars on waking in the morning. Metformin reduces this overproduction of glucose. It helps in lowering the blood sugar, especially after eating, with no risk of hypoglycemia when used alone. Modest improvement in cholesterol levels are also seen. The 10 year UKPDS Study of over 3,000 people with Type 2 diabetes found that those who were placed on metformin had a 36% decrease in overall mortality and a 39% decrease in heart attacks.
Because metformin shuts off the liver’s excess production of glucose, it reduces the amount of injected insulin needed to control the blood sugar in both Type 1 and Type 2 diabetes. People with Type 2 diabetes who are on insulin usually are advised to lower their insulin doses prior to starting metformin. The full improvement in glycemic control and cholesterol levels may not be seen until 4 to 6 weeks of use have passed.
Side effects from metformin include a change in taste, loss of appetite, nausea or vomiting, abdominal bloating or gas, diarrhea, or skin rash. These may occur during the first few weeks of taking the medication but are seldom long-lasting. Taking the medication with food and starting out with a low dose help reduce side effects. The dosage can be gradually increased as side effects diminish.
Lactic acidosis, the serious but rare side effect originally seen with phenformin, results when a buildup of lactic acid occurs due to an inability to clear metformin from the system. Lactic acidosis occurs very rarely, only once in every 30,000 person-years of use. It almost always occurs in older people who have another major health problem, especially one that may impair breathing or circulation. Warning signs of lactic acidosis include fast and shallow breathing, diarrhea, severe muscle aches, cramping, unusual weakness or tiredness, or feeling cold. Because lactic acidosis has a mortality rate of about 40%, anyone who has significant lung disease, congestive heart failure, or kidney disease should never take this drug.
Because drinking alcohol while taking metformin may also trigger lactic acidosis when other health risks are present, be sure to ask your doctor about alcohol consumption if you are taking this drug. Be aware that Tagamet, a gastrointestinal medication, may enhance the effects of metformin. Therefore, the dose of metformin may need to be lower if you already take Tagamet.
Although not yet FDA approved, metformin is now in clinical trials for treatment of teens who have developed Type 2 diabetes. Some pediatricians also prescribe it, on occasion, to help control a strong Dawn Phenomenon seen in a growing teen with Type 1 diabetes. This use is also not approved. It also helps lower insulin resistance in women with polycystic ovary disease. One side-effect for these women, sometimes a desired outcome, is a greater likelihood of pregnancy.
Metformin lowers fasting blood glucose levels by an average of 25% (17 to 37%), postprandial blood glucose up to 44.5%, and the A1c by an average of 1.5% (0.8 to 3.1%). Metformin reduces raised plasma insulin levels in cases of metabolic syndrome by as much as 30% and reduces the need for injected insulin in Type 2s by 15 to 32%.
Metformin is available under the trade name Glucophage, or as an extended-release tablet called Glucophage XR. It works well when combined with sulfonylureas. A combination of glyburide and metformin is available as Glucovance. Combined therapy leads to a greater reduction in blood sugar than can be attained by either class alone. Generic metformin is available at a reduced cost.
Metformin possesses some distinct advantages in treating diabetes. Excess glucose produced by the liver is the major source of high blood sugars in Type 2 diabetes and is typically the reason for high blood sugars on waking in the morning. Metformin reduces this overproduction of glucose. It helps in lowering the blood sugar, especially after eating, with no risk of hypoglycemia when used alone. Modest improvement in cholesterol levels are also seen. The 10 year UKPDS Study of over 3,000 people with Type 2 diabetes found that those who were placed on metformin had a 36% decrease in overall mortality and a 39% decrease in heart attacks.
Because metformin shuts off the liver’s excess production of glucose, it reduces the amount of injected insulin needed to control the blood sugar in both Type 1 and Type 2 diabetes. People with Type 2 diabetes who are on insulin usually are advised to lower their insulin doses prior to starting metformin. The full improvement in glycemic control and cholesterol levels may not be seen until 4 to 6 weeks of use have passed.
Side effects from metformin include a change in taste, loss of appetite, nausea or vomiting, abdominal bloating or gas, diarrhea, or skin rash. These may occur during the first few weeks of taking the medication but are seldom long-lasting. Taking the medication with food and starting out with a low dose help reduce side effects. The dosage can be gradually increased as side effects diminish.
Lactic acidosis, the serious but rare side effect originally seen with phenformin, results when a buildup of lactic acid occurs due to an inability to clear metformin from the system. Lactic acidosis occurs very rarely, only once in every 30,000 person-years of use. It almost always occurs in older people who have another major health problem, especially one that may impair breathing or circulation. Warning signs of lactic acidosis include fast and shallow breathing, diarrhea, severe muscle aches, cramping, unusual weakness or tiredness, or feeling cold. Because lactic acidosis has a mortality rate of about 40%, anyone who has significant lung disease, congestive heart failure, or kidney disease should never take this drug.
Because drinking alcohol while taking metformin may also trigger lactic acidosis when other health risks are present, be sure to ask your doctor about alcohol consumption if you are taking this drug. Be aware that Tagamet, a gastrointestinal medication, may enhance the effects of metformin. Therefore, the dose of metformin may need to be lower if you already take Tagamet.
Although not yet FDA approved, metformin is now in clinical trials for treatment of teens who have developed Type 2 diabetes. Some pediatricians also prescribe it, on occasion, to help control a strong Dawn Phenomenon seen in a growing teen with Type 1 diabetes. This use is also not approved. It also helps lower insulin resistance in women with polycystic ovary disease. One side-effect for these women, sometimes a desired outcome, is a greater likelihood of pregnancy.
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