Choosing insulin? And experience of Avandia?

[rach]

Hi!

Despite the fact I've previously suffered from hypos I'm discovering diabetes has its own agenda and my pancreas appears to have gone downhill rapidly - in the past month BMs have been up to 18 so have had my medication increased from 30mg gliclazide MR, to 60mg, to 90mg. As of yesterday I've been put on 4mg Avandia (rosaglitazone) as well as 90mg gliclazide MR.

However the doctor yesterday mentioned I might benefit from low doses of gliclazide and a short acting insulin with meals.... Is this a possibility? If I were to want to go onto insulin would I be able to or is it very much an "end of the road" thing in type 2/MODYs? I'm not due to see my DSN/consultant for a few months but am wondering whether to contact them or my GP with a query or wait until my next appointment if it's unlikely to be a yes. I've heard of people having to fight to go onto insulin so wasn't sure. Also could people on insulin tell me some of the disadvantages if I'm best to stick to the oral drugs? I am hoping it might iron out some of the highs/lows I'm getting being on two long acting drugs...

Also just been reading about Avandia on the diabetes co uk site... apparently it's best avoided in pre menopausal women... does anyone know why? I'm just a little worried, the doctor never mentioned that!

THank you!

 

[Dennis]

Hi Rach,

I think that most type-2s generally try to avoid insulin for as long as possible because moving to insulin has implications for life, travel and car insurance and potentially your being allowed to hold a driving licence. There are so many alternative treatments that can and should be tried before a doctor resorts to insulin, but unfortunately many GPs see insulin as a short-cut solution. My own consultant describes insulin as "the biggest spanner in the box, but why use the biggest spanner when a smaller one will do the job".

I have personal experience of rosiglitazone. It is a type-2 treatment that carries with it a pretty nasty set of side-effects, which the manufacturers would rather we didn't know about so they choose not to mention them on the patient information leaflet! I was put on it for 6 months by my GP, during which time I put on 5 stone despite being on a strict diet, I suffered severe shortness of breath (couldn't walk more than 100 yards at moderate pace without having to stop to get my breath back), had terrible fluid retention (ankles swelled to double normal size), developed an irregular heartbeat and suffered dizzy spells. I reported the problems to my GP who said he had never heard of any of these being associated with Avandia, but just to be on the safe side, he referred me to a diabetes consultant. The consultant confirmed that these are only some of the known side effects, took me off the drug immediately and within a few weeks all the symptoms had gone (but it took nearly a year to get rid of the 5 stone!). When I asked why the manufacturers are not forced to list the side effects, he could only shrug.

The good news is that there are some people who suffer none of the side effects, although I gather these are a minority.

 

[hanadr]

Hi!

Despite the fact I've previously suffered from hypos I'm discovering diabetes has its own agenda and my pancreas appears to have gone downhill rapidly - in the past month BMs have been up to 18 so have had my medication increased from 30mg gliclazide MR, to 60mg, to 90mg. As of yesterday I've been put on 4mg Avandia (rosaglitazone) as well as 90mg gliclazide MR.

>>Gliclazide thrashes the pancreas<<

However the doctor yesterday mentioned I might benefit from low doses of gliclazide and a short acting insulin with meals.... Is this a possibility? If I were to want to go onto insulin would I be able to or is it very much an "end of the road" thing in type 2/MODYs? I'm not due to see my DSN/consultant for a few months but am wondering whether to contact them or my GP with a query or wait until my next appointment if it's unlikely to be a yes. I've heard of people having to fight to go onto insulin so wasn't sure. Also could people on insulin tell me some of the disadvantages if I'm best to stick to the oral drugs? I am hoping it might iron out some of the highs/lows I'm getting being on two long acting drugs...

>> My GP is trying to get everyone on to insulin, but I'm resisting<<

Also just been reading about Avandia on the diabetes co uk site... apparently it's best avoided in pre menopausal women... does anyone know why? I'm just a little worried, the doctor never mentioned that!
>> Have you reduced your carbs? If not , try it. It's not going to cost anything and doesn't have side effects.<<

 

[Trinkwasser]

Also just been reading about Avandia on the diabetes co uk site... apparently it's best avoided in pre menopausal women... does anyone know why? I'm just a little worried, the doctor never mentioned that!

It can cause bone thinning

(Strange, I read that as postmenopausal, which is where the bone thinning comes in. Probably it is not recommended during pregnancy, just in case that happens without you noticing)

 

[Trinkwasser]

Hi Rach,

I think that most type-2s generally try to avoid insulin for as long as possible because moving to insulin has implications for life, travel and car insurance and potentially your being allowed to hold a driving licence.

That bit I'll go along with, but experience of people I know in the States where early insulin is more often used for Type 2s is that for many of them their first thought is "why wasn't I put on this years ago?"

It takes some using, you need somewhat of a scientific/rational approach, but when you know what you are doing it is much more controllable than trying to wring the last drops of insulin out of a defective pancreas.

Some authorities will start with a long acting basal and see if the pancreatic load is reduced enough that you can use your own output to cover meals, others will start with a short acting insulin and leave your pancreas producing the background stuff depending on level of functioning.

Whatever you decide try doing this for a while

http://www.alt-support-diabetes.org/NewlyDiagnosed.htm

controlling (which usually means reducing) your carbs should help

Do you have lipid panel results? If you have high insulin resistance I'm a bit surprised metformin hasn't been prescribed, it's cheap and effective apart from its possible and often temporary side effects (metfartin)

 

[rach]

Thanks very much for all your advice.

Trinkwasser: I have been tried on metformin (metfartin...love the name!) but couldn't tolerate it - severe vomiting/diarrhoea. I know these reduce with time but no vomiting/diarrhoea was at all practical if I am to carry on with my work and when I mentioned it was taken off it immediately. I've been told I'm MODY and just produce low amounts of insulin (not have resistance to it) and that that was why gliclazide initally worked so well. I had thought the sudden decrease in blood sugar levels was due to my pancreas giving up but might it be possible it is actually rapidly increasing insulin resistance? My lipids were good in November - cholesterol 4.2, triglycerides 0.8, HDL 2.1, LDL 1.3

Trinkwasser and Hana, thanks for the suggestion of carb reduction - I have done that a fair bit. I now eat 80-120g carbs a day (much to the dislike of my GP...she was all eat lots and lots of pasta - hmm). I'm not sure I can really go any lower.... is this likely to be low enough to have an effect? I noticed a huge effect when I first cut down (from over 200g/day).

Dennis: Thank you for the insight into insulin's effects on life. Am I right that it is still possible to drive providing you don't have "debilitating hypos"? (And do you have any idea what debilitating hypos are?!). I found it harder to look up info on travel and car insurance. What sorts of difficulties does it cause? Are they harder to get and cost more, or impossible? Thanks too for the insight on rosiglitazone...they don't tell you ANY of that do they?? Dreading the idea of weight gain, gliclazide has already put me up half a stone eating the same number of calories, which when I weighed 8 stone before is a significant gain. I will watch out for that - unfortunately the consultant didn't take me very seriously about the weight gain when I last saw her as she said I have a normal BMI so it didn't matter. But 5 stone is a lot, and you're right, weight takes ages to come off but no time to go on. Your effects on rosiglitazone sound awful - I'll be watching out. Hopefully I might be in the small number of unaffected people thought... Can always hope!

Thanks again for all your help,
Rachael

 

[Trinkwasser]

Thanks very much for all your advice.

Trinkwasser: I have been tried on metformin (metfartin...love the name!) but couldn't tolerate it - severe vomiting/diarrhoea. I know these reduce with time but no vomiting/diarrhoea was at all practical if I am to carry on with my work and when I mentioned it was taken off it immediately. I've been told I'm MODY and just produce low amounts of insulin (not have resistance to it) and that that was why gliclazide initally worked so well. I had thought the sudden decrease in blood sugar levels was due to my pancreas giving up but might it be possible it is actually rapidly increasing insulin resistance? My lipids were good in November - cholesterol 4.2, triglycerides 0.8, HDL 2.1, LDL 1.3
/quote]

That looks like you actually have *negative* insulin resistance <G>

Have a read round Jenny's blog

http://diabetesupdate.blogspot.com/

she's a MODY now using insulin, may have some pointers for you

Trinkwasser and Hana, thanks for the suggestion of carb reduction - I have done that a fair bit. I now eat 80-120g carbs a day (much to the dislike of my GP...she was all eat lots and lots of pasta - hmm). I'm not sure I can really go any lower.... is this likely to be low enough to have an effect? I noticed a huge effect when I first cut down (from over 200g/day).

May be worth doing some more postprandial testing, us IR folks are far more carb sensitive in the mornings, you may have a different pattern and need to avoid carbs more at different times of day.

Have you tried Alpha Lipoic Acid? This seems to work for some people of which I'm one, but my primary defect appears to be IR and my secondary defect appears to be within the control system, both of which it improves, but I don't have any idea what effect it may have in MODY.

I suspect if the glic isn't cutting it any more, like Jenny you'd be better off on insulin, probably you'd only need tiny doses to supplement whatever your pancreas is still capable of

 

[Dennis]

Am I right that it is still possible to drive providing you don't have "debilitating hypos"? (And do you have any idea what debilitating hypos are?!). I found it harder to look up info on travel and car insurance. What sorts of difficulties does it cause? Are they harder to get and cost more, or impossible?

Hi Rachel,
As regards the driving licence, the DVLA regulations (updated November 2008) say that anyone who is prescribed insulin has to advise the DVLA. You should also give them the details of your GP. They will contact the GP to check your history of hypos and, as long as your GP can confirm that you are safe to drive, then you will be allowed to drive cars (but not HGVs or PSVs) but you must re-apply every 3 years.

Insurance can be problematic. You must advise your car insurers, otherwise if you were ever to need to make a claim, they can (and in most cases will) say you failed to notify them of something that would have influenced their decision to insure you and therefore you are not insured! However, once you have advised them, the majority of insurers simply note their records about your diabetes and treatment and it doesn't raise your premiums.

For travel insurance, being diabetic increases their risk, and the fact that you have moved on to insulin is something they see as marking a significant deterioration in your condition and, although they will insure you, they will often not cover any situation arising from your diabetes. What you can do is to switch to one of the specialist insurers who do cover diabetes. I did that this year and found them to be significantly cheaper than my previous travel insurance.

With life insurance any policy you already have shouldn't be affected - the premium you pay is set at the time you take out the policy and it takes account of any risks the insurer may face as you get older and your health changes. But if you need to take out a new policy, or increase your existing cover, you will find most insurers will hike up the premiums enormously if you are on insulin.