Low carb for doctors: diabetes medications

Let's think for a bit about the patients who are already on drugs for the type 2 diabetes This is something I've worried about quite a lot over the years

And particularly at the beginning I was very concerned So that actually it might for many of you be quite a good thing to start with some of the easier cases and then like me you will gain confidence as the years go by and learn what for you feels comfortable So for me I actually was very cautious and years ago I started just with the pre-diabetics And then I moved on to pick with type 2 diabetes and then my next phase was people on metformin And I discovered actually that it works reasonably well as the weight comes down and the hemoglobin A1c's improve once you're getting somewhere around maybe 47 to 50 mM/mole of hemoglobin A1c you can start cutting the metformin

Now this has to be seen against the patient's views as in all of these things You work in collaboration with the patient, so you've got your own goals but don't forget the patient's goals or anxieties So that again going back to that metformin some patients already have side effects with metformin, particularly loose motions that's very common, so those patients are keen to give it up and I factor that in But usually I'm cutting it down by about half perhaps just leaving them with their morning dose of metformin and then let's do another hemoglobin A1c two months later But it does depend on how much weight they're losing

If they're doing really well you might consider stopping it altogether And all advice against what you're doing with drugs for diabetes would depend upon extra factors like, "Have they got a blood sugar meter?" Because patients with blood sugar meter, you can act faster because you're getting feedback and you know how they are doing So I think after that my next group were those on Gliclazide Now Gliclazide, one of its side effects is weight gain So for many patients, they are interested in giving up Gliclazide because of the advantages of that

So far in my own experience for somebody losing weight, I've given up the Gliclazide totally early on and I've so far not regretted that So that if somebody is really taking up the low-carb thing and understands, I might stop the Gliclazide altogether in a more dramatic sense than I do the metformin Of course after that there are whole other levels of extra drugs perhaps culminating in insulin Now I didn't do anything with people on insulin with type 2 diabetes for the first couple of years, because I was so anxious about that But then again looking at the effects of insulin in type 2 diabetes it's perhaps unfortunate that it causes weight gain and the studies show that insulin is not always the best idea in type 2 diabetes and brings with it real risks of its own

So again in partnership with the patients, reducing insulin can be exactly what they would like to do How you do this depends on factors like, "How reliable is this patient?", if they're on insulin they should be measuring blood sugars, "are they doing it?", when are they measuring those blood sugars One of my partners pointed out that he found his patients were measuring blood sugars first thing in the morning, not after they had food, so the results they were bringing in were causing errors

So are you patients when are they measuring their blood sugars and how interested are they in reducing the insulin in a step or alike manner while watching the blood sugars And also I suppose you would have to share with the patients you're more concerned about a low blood sugar, them going hypo, than you are about it going a bit high

So one or two slight worries I've had with patients is where they've been too keen, the blood sugars dropped low, and these are people driving cars or whatever, so I've now tend to slightly on the idea that is a low blood sugar would worry me more than it going high And it is difficult to be more specific than that, because each case depends upon all those various factors

I'll probably finish off by saying those people who were on insulin for type 2 diabetes are the group who are most proud of their achievements and are amazed when they can actually stop injecting So it is work that is worth doing, although it does take more appointments, because you're watching them more closely But it can be very rewarding to try as long as it's what you patient is really interested in

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