2nd oral med after metformin

[winterallsummer]

What is the 2nd PO med you add once metformin has been maxed out or tittered to ADRs? I have seen a wide variability on my rotation between drugs added and for most practitioners they seem to add what they are used to. Wondering if anyone could post the 2nd drug they add and their reasoning behind it.

 

Also i see pts on 2 drugs but only 1000 mg of metformin. why would one not max out metformin first, assume pt is not c/o ADRs? Thanks in advance to all who reply.

[EMEDPA]

what I see most often is folks maximize lifestyle stuff, max metformin, then start a once daily long acting insulin at bedtime like lantus.

when I volunteer in Haiti insulin is not an option due to the need for refrigeration so we max metformin then add glyburide at low dose then work that up.

maybe some of the primary care folks can chime in.

[fyrelight74]

There's not a whole lot of reduction from 2000mg metformin to 2550mg metformin (max). Most of the time, the patient will need more than that.  If they have insurance, I will then add Januvia (Janumet combo) usually.  I like it because the patient still won't have to worry about dropping too low on those.  The others in the same category as Januvia are just as good (Onglyza, Tradjenta, etc), but most aren't covered by any insurance.  Actos is an option as well.   I'm just not a fan of sulfonylureas.

[ventana]

metformin 1gm BID

 

then Glyburide (oops that just changed with the recent data on metformin) now using glipizide

 

then lantus

 

UNLESS they are a commercial driver - then I throw everything at them and the kitchen sink so they can continue to drive.....

 

 

honestly all the novel oral and injectible DM drugs out there are pretty worthless in my eyes, most are less then 1 reduction in HgA1c and cost is big..... I just don't use them....  I also tell newly Dx Type II of the disease progression is for them to end up on insulin.... they hear it on the first visit.... and keep hearing it......

[GetMeOuttaThisMess]

V, I like your point about the driver. What's the point some may ask? Automatic disqualification for a FMCSA DOT medical certificate IF on insulin. You can challenge but no one has ever received a waiver as of two years ago. The key thing to bear in mind, studies tell us two things: one, if HbA1c >9%, start insulin because in most cases maximum oral therapy will drop it no greater than 2% (arbitrary goal is 7% but nothing magical about that number). Second, we (providers) are notoriously late in starting insulin for a multitude of reasons and that is ultimately what the patient needs to delay progression of secondary complications. It's not the disease, it's the secondary complications.

[EMEDPA]

yup, agree with above. maxed metformin drops a1c by 1.

it's got to be about lifestyle if they want to stay off insulin; exercise/wt loss/appropriate diet/etc

[PASomeday]

I would exhaust orals before putting them on insulin.

 

2nd agent after metformin depends on type of patient. I'd add glipizide to someone who's in tune to hypoglycemic sx and can adjust dose accordingly.

 

However, I'd add something more forgiving like Januvia in an elderly patient or someone who's not as mentally acute in detecting hypoglycemic sx, so I don't have to worry about them not adjusting their dose accordingly.

 

I don't like metformin in elderly pts with renal insufficiency.

My 2 cents as a pharmacist w/recent experience helping manage elderly relative's type 2 diabetes.

 

[bradtPA]

If they can afford it, and it's not contraindicated due to patient history I prefer to go to a GLP-1 agonist such as Victoza after metformin because of the synergistic effect and data on weight loss.

[Joelseff]

There's not a whole lot of reduction from 2000mg metformin to 2550mg metformin (max). Most of the time, the patient will need more than that. If they have insurance, I will then add Januvia (Janumet combo) usually. I like it because the patient still won't have to worry about dropping too low on those. The others in the same category as Januvia are just as good (Onglyza, Tradjenta, etc), but most aren't covered by any insurance. Actos is an option as well. I'm just not a fan of sulfonylureas.

I like januvia for adjunct therapy also. It doesnt promote hypo and can make an impact on that A1C. New kids on the block Onglyza-reps are really on me to start a pt on this-is an injectable and I work in Oakland. To my pts an injectable medication for DM is insulin, regardless of the truth. I already have enough of a hard time for them to use insulin when I need to start them. That aint gonna fly here. And besides it is tier 2 at best on insurances and that surely wont fly here.

 

Sent from my Galaxy S4 Active.

 

[cbrsmurf]

The second-line options after metformin suck.  Metformin is the ONLY medication (including insulin) in type 2 that reduces mortality.  Your DDP-IV inhibitors (onglyza, januvia) have questionable efficacy and can cause pancreatitis - see recent (a couple months ago) NEJM-published studies that they are about equal to placebo.  Everything else, sulfonyureas (yay hypoglycemia), TZD's (yay heart failure and bladder cancer) and incretins have poor evidence at best that they reduce mortality.  The recent update in ADA guidelines for less stringent/low a1c targets reflects the evidence that tight glycemic control is not as useful as we once thought and especially in elderly patients can increase mortality.  

 

In conclusion, I put very little stock in the second line oral diabetic medications.  They are usually expensive, barely makes a dent in a1c, and probably does not decrease your CV risk or mortality.

 

Oh, and check renal function, maybe that's why the metformin isn't maxed out. 

 

Oh, and also an increase of a1c from 7 to 9% increases your chances of ESRD, retinopathy, cvd much less than what one would think.

[AREID]

Metformin followed by glipizide. Glipizide is cheap and it works. The key is DIET!!! You can throw all the meds you want at a patient but if they are eating everything under the sun, the glucose will not change. It seems as if nutrition information is something that is sorely lacking.

Some basic concepts:

Carbs = sugar

Fruit = sugar

Juice/milk = sugar

Brown whatever will still cause your glucose to rise, albeit at a much slower rate

Small meals spaced throughout the day (5-6/day) allows your body to metabolize what it needs without over stressing the pancreas

 

 

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[EMEDPA]

Brown whatever will still cause your glucose to rise, albeit at a much slower rate

 

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mmmmmm, brown sugar and caramel......(kidding....:) )

[ventana]

The second-line options after metformin suck.  Metformin is the ONLY medication (including insulin) in type 2 that reduces mortality.  Your DDP-IV inhibitors (onglyza, januvia) have questionable efficacy and can cause pancreatitis - see recent (a couple months ago) NEJM-published studies that they are about equal to placebo.  Everything else, sulfonyureas (yay hypoglycemia), TZD's (yay heart failure and bladder cancer) and incretins have poor evidence at best that they reduce mortality.  The recent update in ADA guidelines for less stringent/low a1c targets reflects the evidence that tight glycemic control is not as useful as we once thought and especially in elderly patients can increase mortality.  

 

In conclusion, I put very little stock in the second line oral diabetic medications.  They are usually expensive, barely makes a dent in a1c, and probably does not decrease your CV risk or mortality.

 

Oh, and check renal function, maybe that's why the metformin isn't maxed out. 

 

Oh, and also an increase of a1c from 7 to 9% increases your chances of ESRD, retinopathy, cvd much less than what one would think.

 

 

well put - spoken from years of experience and a reasonable amount of doubt against $300/month meds that might drop your A1C 0.7% but also really don't have enough data out to say they are really safe......   remember the whole HRT  and how it was 'supppppposed' to lower CAD risk.....  ooopppsss on that one.....   and I suspect a lot of the novel DM meds are just money makers

 

 

If someone is not a commercial driver just get them on insulin early.... we all delay to much on this topic - I am telling everyone at time of Dx that the natural ds progression is to end up on insulin, you never get "cured" but you can go into remission if you exercise and loose weight and eat healthy.  

 

 

Honesty the resistance to insulin goes away after about 1-2 weeks of using it when people realize it works and is simple (once you get the hang of it)

[winterallsummer]

For starting pt's on insulin, 2 questions.

 

1. d/c the metformin or continue it?

 

2. start a basal insulin, or a medium/short combo (70/30)?

[sbellin]

The ADA has aptly moved away from stating that we should be treating everyone to a specific A1C number I think for a variety of reasons; they make recommendations for goals.  In adding a second or third agent the prescriber must recognize what goal they hope to achieve with their intervention ( do we need an A1c of 7 in a 95 year old?), what are the risks of reduction ( increased risk hypoglycemia, weight gain/fluid retention), what are the costs to the patient ( financial, jobs loss with adding insulin), and is it really gonna make any difference in the long run in that particular patient. Adherence to a medication and treatment plan that the patient themselves ascribe is worth much more than any add on agents.  I also think an A1c is only a rough guide as to how the patient has done and must be interpreted with caution in subjects that have wide swings in their day to day sugars or that have home monitoring that contradicts the A1c.  As for the question of what's the best second line agent it depends. 

[fyrelight74]

I generally continue the metformin and add a basal insulin when it is time to add insulin.

[GetMeOuttaThisMess]

Short answer, it isn't about the HbA1c, it's about preventing secondary disease processes. No study shows that 6.5-7% is the be all, end all. If you follow the guidelines that I'm familiar with max metformin, add second oral med, then go to insulin. Think about physio/pathophysio. All metformin does is decrease hepatic glyconeogenesis. Insulin is used to mimic normal physiologic function. Start long-acting basal depending on whether or not the magical HbA1c is >2% above goal to maintain natural baseline insulin secretion. As has been pointed out previously, get them to "lose a person", exercise, and eat reasonably. If this doesn't work then you need to advance to "rocket science" and start the short-acting insulin to

mimic post-prandial response. With type II, non-insulin, major question in F/U is to inquire as to hypoglycemic issues, O/W make sure annual screening recommendations are done and get them a darn PCV that everyone always forgets. Unless they're newly diagnosed and want to see how different foods affect their sugars, I don't care to see BS readings. Just look at the HbA1c as long as their not exhibiting hypoglycemic sx's.

[ventana]

Firstly, it reduces the amount of sugar produced by cells in the liver. Secondly, it increases the sensitivity of muscle cells to insulin. This enables the cells to remove sugar from the blood more effectively. Finally, it also delays absorption of sugar from the intestines into the bloodstream after eating. Overall, metformin reduces blood sugar levels both between and directly after meals.

Read more: http://www.netdoctor.co.uk/diabetes/medicines/glucophage.html#ixzz2mpBiYn00 
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[AREID]

Keep metformin. It Increases insulin sensitivity, which allows you to use less insulin. Insulin causes weight gain which causes a need for more insulin.

 

Don't be fooled into thinking that meds only drop A1C levels by 1%. In the patient who has never taken medication and is uncontrolled, they can easily go from a 13 to an 8 in a few months. Once we max out, THEN it becomes more difficult.

 

Finally, NUTRITION is the key. Learn the basics of what will and won't cause glucose to rise

 

 

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