Can anyone explain the different approaches to medication?

[TooManyCrisps]

I've been reading this forum a lot recently and it's struck me that when people are first diagnosed, the treatment from their GP seems to vary hugely and I was just wondering why.

So, you read things like "I was diagnosed with an HBA1C of 68 so I was put on insulin". "My HbA1c on diagnosis was 72 so I was put on Metformin" etc. There doesn't seem to be consistency about what reading should trigger what treatment.

My experience was having an HBA1C of 97 at diagnosis, and my GP saying he could prescribe metformin straightaway but it had possible side effects, or I could try to lose some weight (my BMI was 31) and modify my diet. I chose to do the latter.

I just find it surprising that some GPs go straight to prescribe insulin for a much lower HbA1c than mine was, others seem to think metformin is the only option for anyone, and others (like mine) think of diet modification even with a high HbA1c.

Of course, in many cases on here we don't know the background history of the posters so there may be other factors which lead a GP to decide on one treatment rather than another. I was just really taken aback reading a poster earlier who said she'd been put straight onto insulin because her initial HbA1c was 67. I would have thought other options would have been tried first.

So, does anybody know if there are guidelines for GPs around what treatment to offer? Or is it just dependent on the GP - in which case I was very lucky with mine.

 

[catapillar]

So, does anybody know if there are guidelines for GPs around what treatment to offer?

There are indeed guidelines, NICE guideline 28 contains the guidelines on type 2 diabetes, and this algorithm on drug therapies - https://www.nice.org.uk/guidance/ng...in-adults-with-type-2-diabetes-pdf-2185604173

 

[Sid Bonkers]

There are of course guide lines but never forget that we are all different and the person who was "68 and put on insulin" may have been on prednisolone or some other bg raising medication for a totally unrelated condition or there may be some other reason why they were put on insulin, you cant tell from a short post on a forum.

We never know all of any members medical history which is why it is so dangerous to give medical advice on a forum, no doctor would ever try to give advice or treat a patient without knowing that persons full medical history.

Medical treatment in general varies because it may be tailored to the individual, of course thats not to say that mistakes are not made and some people are misdiagnosed and or given the wrong choices but unfortunately, thats life.

General advice like trying to reduce the carbs in your diet or avoiding "diabetic foods" is fine but if you are concerned with anything to do with your treatment the only person to speak to is your GP or someone else from your diabetic team, not someone on an internet forum.

You only know half the story with most posters on any internet forum, you get to hear what people want you to know, whether that is fact, fiction or the whole truth or a tissue of lies we can never be sure so take it all with a pinch of salt, this is after all an internet forum not a diabetic clinic.

 

[leslie10152]

I've been reading this forum a lot recently and it's struck me that when people are first diagnosed, the treatment from their GP seems to vary hugely and I was just wondering why.

So, you read things like "I was diagnosed with an HBA1C of 68 so I was put on insulin". "My HbA1c on diagnosis was 72 so I was put on Metformin" etc. There doesn't seem to be consistency about what reading should trigger what treatment.

My experience was having an HBA1C of 97 at diagnosis, and my GP saying he could prescribe metformin straightaway but it had possible side effects, or I could try to lose some weight (my BMI was 31) and modify my diet. I chose to do the latter.

I just find it surprising that some GPs go straight to prescribe insulin for a much lower HbA1c than mine was, others seem to think metformin is the only option for anyone, and others (like mine) think of diet modification even with a high HbA1c.

Of course, in many cases on here we don't know the background history of the posters so there may be other factors which lead a GP to decide on one treatment rather than another. I was just really taken aback reading a poster earlier who said she'd been put straight onto insulin because her initial HbA1c was 67. I would have thought other options would have been tried first.

So, does anybody know if there are guidelines for GPs around what treatment to offer? Or is it just dependent on the GP - in which case I was very lucky with mine.

I was put straight onto insulin on diagnosis, yet other around me were prescribed metformin and diamicron. Some GP's tend to go to insulin depending on the state of the diabetes on diagnosis.

 

[Art Of Flowers]

My GP told me to lose weight, exercise more and check out diabetes.co.uk as it had a lot of useful info. I was put on 2x500 Metformin. The diabetes nurse told me that diabetes is usually a progressive degenerative disease and requires more and more medication over time. She was shocked that I reduced by HbA1C from 99 to 59 in four months, so I expect most people with type 2 only get small reductions in blood sugars as they are relying on pills and not diet to treat diabetes. My diabetes nurse told me that only one other of her patients was on a LCHF diet.

In general, the medical profession seems to be not clued up on low carb diets or fasting as treatment for type 2 diabetes. Some are, such as Dr Jason Fung. It is interesting to watch his video: The Two Big Lies of Type 2 Diabetes. He managed to get patients who had diabetes for over 20 years on high doses of insulin completely off medication in about 10 weeks using a combination of low carb diet and fasting.

 

[TooManyCrisps]

There are of course guide lines but never forget that we are all different and the person who was "68 and put on insulin" may have been on prednisolone or some other bg raising medication for a totally unrelated condition or there may be some other reason why they were put on insulin, you cant tell from a short post on a forum.

We never know all of any members medical history which is why it is so dangerous to give medical advice on a forum, no doctor would ever try to give advice or treat a patient without knowing that persons full medical history.

Medical treatment in general varies because it may be tailored to the individual, of course thats not to say that mistakes are not made and some people are misdiagnosed and or given the wrong choices but unfortunately, thats life.

General advice like trying to reduce the carbs in your diet or avoiding "diabetic foods" is fine but if you are concerned with anything to do with your treatment the only person to speak to is your GP or someone else from your diabetic team, not someone on an internet forum.

You only know half the story with most posters on any internet forum, you get to hear what people want you to know, whether that is fact, fiction or the whole truth or a tissue of lies we can never be sure so take it all with a pinch of salt, this is after all an internet forum not a diabetic clinic.

Hi
Yes, you're absolutely right that we don't know other people's medical history. I guess I hadn't realised that for some people going straight to insulin is the only option. I think the poster in question had phrased it something like "My HbA1c was 68 so the GP put me straight onto insulin" as if the reading was the only factor. But of course it could be influenced by many other factors.

In my case, I'm not sure whether my age was also a factor (I was 49 at diagnosis). I do remember the GP saying it was worth trying LCHF dieting because I had a defined waist, if I was apple shaped it would be less likely to work. Nor sure if that's a medical fact!

 

[TooManyCrisps]

There are indeed guidelines, NICE guideline 28 contains the guidelines on type 2 diabetes, and this algorithm on drug therapies - https://www.nice.org.uk/guidance/ng...in-adults-with-type-2-diabetes-pdf-2185604173

Thanks, that's really interesting. I hadn't realised that insulin is recommended at such a (relatively) low HbA1c. Although not as a first option.

I'm really pleased my GP was so supportive of me trying LCHF eating and that I got all the support and advice I needed on this forum.

I did go on a DESMOND course last year and lots of the participants were taking metformin, there didn't appear to have been much discussion with their GP over lifestyle other than general advice to avoid sugar and lose weight.

 

[Squire Fulwood]

When I was first diagnosed (2009) there was virtually no consideration of an appropriate diet for diabetics. There were the diet sheets that they gave everybody which said things like eat wholemeal bread, skimmed milk etc. but nothing for us.

DN had a computer screen with a flow chart and it told her which pills to give me. That was it, nothing else. She didn't even tell me what my Hba1c was and one of my prize possessions is the post-it note she gave me with the number on it.

My point is that things have progressed much in the last couple of years but the knowledge has not reached every surgery. You still hear of doctors who make threats if you don't take your statins or metformin or whatever is their favourite. More and more you hear of patients being offered the diet option but that is not universal yet. Basically, treatment varies because Type 2 diabetes was thought of as a fat person's thing, is progressive with amputations followed by death. They simply didn't know how to treat it and there are places where they still don't.

 

[gangadharan_nair]

A combination therapy of insulin and other antidiabetic drugs appears to be most beneficial in diabetic patients who still have residual insulin secretory capacity. A combination of insulin therapy and sulphonylurea is more effective than insulin alone in treating patients with type 2 diabetes after secondary failure to oral drugs, leading to better glucose profiles and/or decreased insulin needs.
I am taking insulin (Human Mixtard 30/70) because I am diagnosed with Non alcoholic cirrhosis.
Source:--
https://en.wikipedia.org/wiki/Insulin_(medication)

 

[Bluetit1802]

I cannot understand why insulin or drugs that stimulate insulin production are given to people willy nilly when the amount of natural insulin they produce themselves has never been measured."Oh your insulin isn't working properly so let's give you some more." What is the sense in this? It is high levels of insulin in the body that make people fat. It is after all a fat storing hormone. Much of it ends up round the liver and pancreas, making diabetes worse, and no doubt many other problems as well. Surely insulin levels should be measured and any insulin resistance should be dealt with first and foremost, and only after that has been dealt with should additional insulin be considered. In my humble and non scientific opinion.

Edit to add that of course some people will have a sick pancreas and not be producing enough and may need it, or have such very high levels that a short course in insulin is necessary

 

[lindisfel]

I cannot understand why insulin or drugs that stimulate insulin production are given to people willy nilly when the amount of natural insulin they produce themselves has never been measured."Oh your insulin isn't working properly so let's give you some more." What is the sense in this? It is high levels of insulin in the body that make people fat. It is after all a fat storing hormone. Much of it ends up round the liver and pancreas, making diabetes worse, and no doubt many other problems as well. Surely insulin levels should be measured and any insulin resistance should be dealt with first and foremost, and only after that has been dealt with should additional insulin be considered. In my humble and non scientific opinion.

Edit to add that of course some people will have a sick pancreas and not be producing enough and may need it, or have such very high levels that a short course in insulin is necessary

Exactly Blue tit, insulin in T2D is not a Get out of Jail Free card! It was interesting to see how Dr. Rangan Chattergee tackled an eleven year boy who was very overweight! He checked his insulin as well as his biome. He had a massive amount of insulin although his blood glucose was still controlled but he was on the way to it not being controlled. He put him on a variant of the low carb/ fats diet and he lost a lot of weight in two months and his insulin came right down to normal on the next test. If insulin were tested in the population at large I think a lot of people would get a shock! D.

 

[Chook]

Exactly Blue tit, insulin in T2D is not a Get out of Jail Free card! It was interesting to see how Dr. Rangan Chattergee tackled an eleven year boy who was very overweight! He checked his insulin as well as his biome. He had a massive amount of insulin although his blood glucose was still controlled but he was on the way to it not being controlled. He put him on a variant of the low carb/ fats diet and he lost a lot of weight in two months and his insulin came right down to normal on the next test. If insulin were tested in the population at large I think a lot of people would get a shock! D.

Yes, I enjoyed that programme, too. It just goes to show what a good doctor can do if he's got the time.

 

[Lampman]

I must admit I was surprised when I first met the doctor who diagnosed me. I had been called by her after a routine blood test for another medication, as she wanted me to go for another. She said it was because my blood glucose was high so I had some warning. I checked on the surgery list about her, as I had not seen her before. I also started reading up on diabetes. This doctor is the one in the practise who deals with diabetics, and it seems they may not have a diabetic nurse so she does tests like the one for feet herself. Appointments with her are much longer than the standard 5 mins and out, so she gets time to explain and talk with the patients. She told me a great deal, and sounded me out about my attitude. Being a talker, I did not just sit there, I asked questions and told her my thoughts on changing my diet and lifestyle. She gave me details of the DESMOND course which I attended, and suggested to me I should try diet and exercise first. How does that differ from most experiences? If your GP is just one of the practise and does not specialise, maybe they just don't have the knowledge or time to do more than follow guidelines? The guidelines say not to encourage most T2's to get a meter, which she followed, but I did and it has proved its value. I was delighted to have the chance to be able to change diet and learn from it. In my case it paid dividends and I lost a lot of weight and greatly lowered my levels by my next HbA1c. The doctor was full of praise, and mentioned then that she had not wanted to put me on any medication. Was it because I talked and made it clear I was going to give it my best shot? Who knows, but it is a thought!

 

[Chook]

I must admit I was surprised when I first met the doctor who diagnosed me. I had been called by her after a routine blood test for another medication, as she wanted me to go for another. She said it was because my blood glucose was high so I had some warning. I checked on the surgery list about her, as I had not seen her before. I also started reading up on diabetes. This doctor is the one in the practise who deals with diabetics, and it seems they may not have a diabetic nurse so she does tests like the one for feet herself. Appointments with her are much longer than the standard 5 mins and out, so she gets time to explain and talk with the patients. She told me a great deal, and sounded me out about my attitude. Being a talker, I did not just sit there, I asked questions and told her my thoughts on changing my diet and lifestyle. She gave me details of the DESMOND course which I attended, and suggested to me I should try diet and exercise first. How does that differ from most experiences? If your GP is just one of the practise and does not specialise, maybe they just don't have the knowledge or time to do more than follow guidelines? The guidelines say not to encourage most T2's to get a meter, which she followed, but I did and it has proved its value. I was delighted to have the chance to be able to change diet and learn from it. In my case it paid dividends and I lost a lot of weight and greatly lowered my levels by my next HbA1c. The doctor was full of praise, and mentioned then that she had not wanted to put me on any medication. Was it because I talked and made it clear I was going to give it my best shot? Who knows, but it is a thought!

I think its the luck of the draw - and I think you've been very lucky. My GP is the one in his practice who specialises in diabetes in this area. A couple of years ago he described low carb diets as 'hippy dippy' and said he couldn't support me in it. He might have changed his attitude by now but I doubt it and try to avoid him at all costs. On a few occasions I've got to the reception and been told that I've been switched on to his appointment schedule and its never gone well. He just taps away at his computer and doesn't look at me. I know he is aware of how I manage my diabetes and he is also aware that I no longer need insulin and some other meds - and that my HbA1C is low but never, not once has he mentioned it to me - or asked me how I've managed it.

Sadly he's the only doctor in this village and the next small town that 'specialises' in diabetes so all newly diagnosed get to see him and I know he's still telling newly diagnosed people that they should eat plenty of 'healthy' carbs with every meal.

 

[bulkbiker]

A combination therapy of insulin and other antidiabetic drugs appears to be most beneficial in diabetic patients who still have residual insulin secretory capacity

Sorry have to disagree with you 100% and say that major dietary change is much more effective for a large number of people if they are informed about it.

This site has generated a large volume of data on Low Carb eating and its effects on Type 2 which is being disseminated by presentations at various low carb gatherings.. Dr's Jason Fung, David Unwin, Ranjan Chatterjee and many others are having great success with dietary modifications. Insulin therapy is believed by many to be counter productive in the treatment of Type 2 - we do not have a problem with not producing insulin we are resistant to it so introducing even more is not a very effective treatment.

 

[Goonergal]

I do remember the GP saying it was worth trying LCHF dieting because I had a defined waist, if I was apple shaped it would be less likely to work. Nor sure if that's a medical fact!

Well I'm a definite apple shape and LCHF is working just fine!

 

[kokhongw]

A combination therapy of insulin and other antidiabetic drugs appears to be most beneficial in diabetic patients who still have residual insulin secretory capacity. A combination of insulin therapy and sulphonylurea is more effective than insulin alone in treating patients with type 2 diabetes after secondary failure to oral drugs, leading to better glucose profiles and/or decreased insulin needs.
I am taking insulin (Human Mixtard 30/70) because I am diagnosed with Non alcoholic cirrhosis.
Source:--
https://en.wikipedia.org/wiki/Insulin_(medication)

This is the result of prevailing glucose centric treatment and the misguided assumption that T2D has insufficient or inefficient insulin. Although inefficient insulin is semantically correct, it has been framed in such a way that very few understands it as excessive insulin response. Once we realise that T2D is largely the result of excessive insulin response, than the treatment approach would be radically different.

We would then seek to minimize the insulin response thru dietary intervention to allow the exhausted beta cells to recover. That explains the underlying rationale for the remarkable success of low carbs high fats.

Certainly early short term insulin therapy has shown to have some similar effects in some studies by the big 3 insulin makers. But it is clear where their intent is.

Many other studies have shown that the use of sulphonylurea leads to accelerated beta cells exhaustion and loses its effectiveness. It is a high price to pay for a short term, minimal HbA1c improvement.