November 29, 2006

Metformin vs Metformin ER

I'm seeing quite a few posts on BBSes from people who are having problems with metformin because of side effects that could be eliminated if they were taking the extended release form of this drug.

For some reason, many family doctors don't seem to be aware that there is a ER version of this drug that has such benefits. This is probably because metformin is a cheap generic and isn't promoted by herds of beautiful ex-cheerleaders turned drug company salespushers who "educate" doctors about far more expensive--and less effective--newer drugs.

Here are the facts: Metformin (also sold under the brand name Glucophage) comes in a regular version which is taken at meal time, three times a day, and an extended release form (marketed as ER or XR) which is taken once a day.

Almost always, when people report diarrhea or intense heartburn with metformin, they are taking regular version. I experienced the heartburn on the regular drug. It was very disturbing because the pain was localized over my heart and felt just like the description of a heart attack you read in articles. My doctor assured me it was coming from the metformin, but that didn't make it any easier to live with because I kept wondering how, if I were having a real heart attack, I'd know it wasn't a pain from the drug?

The ER version releases the drug more slowly and this usually eliminates the gastrointestinal problems.

The trade off with taking the ER form is that the amount of blood sugar lowering you see might be a bit less than with the regular form as the drug acts in a slower smoother fashion rather than hitting all at once. But if you can't take the regular at all drug because of the side effects, the slight weakening in effect is a reasonable trade off. Plus, you only have to remember to take one dose rather than three. For me, this is not a trivial benefit. Even remembering to take one dose a day is sometimes a challenge!

One important point that my doctor missed when prescribing the ER version of metformin is this: The maximum dose of Metformin ER is LOWER than the maximum dose of regular Metformin.

According to the prescribing information, the maximum dose of the ER is 2000 mg a day. That of the regular is 2550 mg/day. Don't count on a pharmacist to catch the error if your doctor prescribes too much. Mine didn't, but I felt distinctly unwell on the high dose, and a quick look at the prescribing information online showed me the error.

Fortunately, a metformin overdose appears to be surprisingly benign. People have survived suicide attempts where they swallowed as much as 85 grams of the stuff at once. (They did develop lactic acidosis, which can be fatal, but survived.)

The dose at which metformin is supposed to be effective for most people is 1500 mg per day, though I know some smaller people who find a dose of 1000 mg effective. Your body weight will make a difference here, so if you are very large, you may need the maximum dose. In any event, don't conclude that metformin doesn't work until you have tested the dose up to the maximum.

It also takes up to two weeks for the full effect of metformin to become evident. While I will see an increase in my blood sugars if I forget a single day's dose, if I stop the drug for two weeks I see a slow rise in blood sugars through this period. My guess is that this two stage effect is because metformin works both on the liver (where it reduces the release of glucose) and the muscle (where it tricks the tissue into thinking it has just exercised and thus ramps up its burning of glucose). Whatever the explanation, give the drug a few weeks to see what it really does.

Also, many people who experience gas after taking metformin find that cutting way back on their intake of starchy carbohydrates helps eliminate the problem.

Because you only take metformin ER once a day you might wonder what happens if you take it a few hours earlier than usual. Will this cause a dangerous overlap? My experience has been that this isn't a problem. I suspect that the drug does not release evenly over the 24 hours it is supposed to act, and by 20 hours it is pretty much done, so there is no need to be obsessive about taking it at exactly the same time each day.

If I completely space out and don't remember to take the drug for 5 or 6 hours, though, I usually only take half my dose because that way when I take the normal dose at the usual time I don't have too much overlap to worry about.

I have found that there can be significant differences in how the different manufacturers' versions of generic metformin affect my blood sugar. The version I'm taking now, the 750 mg ER pill manufactured by Teva, does not seem to be quite as slow in releasing the drug as other brands are, so I get a much stronger effect during the day, but it wears off by the next morning. Other brands last better through the night, but I don't get anywhere near as good post-prandial numbers at lunch and dinner.

Not so coincidentally, the Teva version of metformin ER comes in a compact, flecked pink pill, while the other versions are pillowy white pills that appear to involve an indigestible matrix in which the drug is embedded. I suspect that the pillowy stuff works a bit better at slowing the digestion of the drug which makes the Teva version sort of a semi ER/semi regular version. That works for me.

I've tried splitting the dose to even out the response, however, I find that if I take Metformin in the evening I end up having to get up to pee at night more than usual. Since this is already a problem for me, I prefer to take it in the morning.

Finally, both Metformin and Metformin ER are currently available for a $4 copay at Wal-mart pharmacies offering the $4 copays on selected generics.

November 20, 2006

Converting Blood Sugar Measurements from mg/dl to mmol/L

It's easy to convert blood sugar measurements reported using the U.S. style of blood sugar measurements using mg/dl to the kind used in the rest of the world that use mmol/L.

Just multiply the mmol/L measurement by 18.05 to get the US measurement.

Divide the U.S. measurement by 18.05 to get the measurement used in the rest of the world.

If you don't have a calculator handy, forget the fraction and use 18. It's close enough.

Here's a handy online calculator that does the conversions for you:

November 15, 2006

Novolog works for me!

If you've been following my Adventures with Insulin you might have read about how I gave up trying to make Humalog work for me. No matter how I tried to use it, I'd see surprising highs and surprising lows. The more I took it the worse it got. I concluded it either wasn't matching up with my food properly or it was sparking the growth of antibodies which were blocking its effect for an hour or so.

What a nice surprise to discover that Novolog, in contrast, does exactly what it is advertised to do. It starts to work within 5 minutes of injection, peaks between 1 hour and 1.5 hours (when my food peaks) and is mostly gone by 3 hours.

This means I can now eat a a restaurant and NOT have to inject until I see the waitress bringing the food. No more chugging smarties while no food appears and I wonder if they'll ever sober up the cook enough to get out my dinner!

For example, last week I brought some along when I went to a new restaurant that had advertised Jamaican Patties, something I adore. If I was using R I would have had to inject almost an hour before eating and if I didn't eat the patty I'd have to come up with 15-20 grams of carbs fast.

With the Novolog, I was able to order my patty and take a look at what I got before injecting. After it was served I had grave doubts about whether I would want to eat it. One bite confirmed that the crust was disgusting. Since I had no insulin in me, I could just pick out the filling (all meat), throw away the crust, and not worry about having a couple units of insulin flying around my blood stream. Three cheers for Novolog!

Though the Novolog is perfect for eating out, I still prefer R insulin for those meals that I make myself where I know what to expect and can inject 45 minutes before the food comes out of the oven.

What I like about R insulin is that I don't usually eat big meals, I like to kind of nibble at this and that through the evening. R's slower pattern of absorption lets me browse my food over a couple hours rather than eat all at once.

The other thing I like about R insulin is that it is just slow enough that a dinnertime shot will get my blood sugar to a good place when I'm done with my evening nibbling. The way my blood sugar works, if it is good at night when I stop eating, it is good first thing in the morning, too. This is a characteristic of the kind of MODY diabetes I have. This means that if I use R insulin I don't have to fool with basal insulin.

November 14, 2006

Does Red Meat Cause Cancer - or Meat & Potatoes?

The latest report from the Nurses Study claims to have found that, based on reports by study participants recalling what they ate, those who say they ate more than one serving of "red meat" a day were more likely to develop breast cancer.

My immediate thought here was this: is the problem something in red meat, which does not as far as anyone knows contain anything that would promote breast cancer, or is the problem that "red meat" mostly means hamburgers on carb-laden buns with piles of fries consumed at a fast food joint, or steak and potatoes, perhaps with a killer carb "Death by Chocolate" dessert, elsewhere?

Why is this significant? Because we ALREADY KNOW THAT THE HIGH BLOOD SUGAR CREATED BY A HIGH CARBOHYDRATE INTAKE PROMOTES CANCER GROWTH. Cancer cells grow much faster than normal cells and they need a lot of glucose to do that growing.

So it is quite reasonable to conclude that people who eat a lot of bread and potatoes along with their "meat" along with the supersized Coke that comes almost for free with the burger and fries special, would be much more likely to have the high blood sugars that feed baby cancer cells.

So what happens when people eat red meat WITHOUT the high carb sides? Do they get cancer? We'll never know because the researchers didn't ask.

Because, once again, researchers were blinded by religiously held beliefs--"red meat is bad for you, carbohydrates are good" rather true science which looks past belief to find explanations, the researchers did not tease out the meat from the potatoes, buns and sodas. So we'll never really know if it is meat or the many very high carbohydrate foods people usually eat ALONG with meat that promoted these cancers.

November 10, 2006

A Perfect Example of a Completely Flawed Study

Soy Yogurt Could Help Control Diabetes

An alert reader sent me this saying that this study proved fruit yogurt may control Type 2 diabetes.

A more perfect example of flawed research would be tough to find.

1. The study concludes that blueberry soy yogurt "controls" diabetes because it has more of a phytochemical which inhibits the enzymes that break down sugars than the other fruit yogurts it was compared to.

In this study one fruit yogurt (full of sugar, of course!) is only compared to other fruit yogurts with even more sugar as far as how much phytochemical it contains.

Note also that a pharmacetuical drug that completely inhibits the same enzymes has at best a very weak affect on blood sugar and only in people with very mild blood sugar abnormalities--the drug Precose. This drug and its drawbacks is discussed at Acarbose the Real Starch Blocker The tiny amounts of phytochemicals found in this yogurt, of course, would have a far weaker effect.

2. The researchers drew all their conclusions about "controlling diabetes" from the presence of these phytochemicals in the food. They did not observe the effect of the sugary fruit-filled yogurts on blood sugar. Fruit yogurt is full of sugar--usually 23 grams per serving, often more. That is enough to propel most of us into dangerous blood sugar territory.

3. The researchers claimed that soy fruit yogurt lowered ACE, a hormone involved with the regulation blood pressure, more than other yogurts. I imagine it also lowered it more than Milky Ways and chocolate cake. This does NOT make it a drug in food form.
Furthermore, they extended this finding about the effect on ACE to make the claim that their sugary fruit yogurt lowers blood pressure. That was not actually examined in this study. Again, the powerful pharmaceutical drugs that suppress ACE only work for people with diabetes in relatively large doses, probably hundreds of times higher than the amount of the phytochemicals found in the sugary yogurt.

4.One major company that makes soy yogurt, LightLife, coincidentally happens to have headquarters located near the UMASS lab. (In Turners Falls, two miles from my house. So I know what I'm talking about.) Lightlife was recently purchased by Conagra, a huge conglomerate that grows soy for the plastic industry and is always looking for ways to sell the excess soybeans. The article does not disclose whether LightLife/Conagra funded this study or others being done at this nutrition lab. Wanna guess if they were?


The article concludes that, of course, everyone knows that a diet high in fruit and whole grains is what diabetics need.

Would someone send this lab a blood sugar meter and ask them to observe the effect on blood sugar of their fruit and sugar-laden yogurts compared with, say, a nice piece of chicken breast with cheese?

November 9, 2006

If I'm Dreaming, Don't Wake Me Up!

I picked up my local newspaper this morning and there on the front page were three headlines so wonderful I had to pinch myself to make sure I wasn't still sound asleep dreaming up a complete fantasy fulfillment!

Here are the headlines from our front page:

1. Dems control Congress!

2. Rumsfeld resigns!

and--Drum roll please . . .

3. Low-carb OK'd for women: new study shows diets high in fat and low in carbohydrates do not pose added risk of heart disease to women

If this keeps up, my blood sugar is going to be dropping just from a lack of things to get infuriated about!

November 3, 2006

What is a Normal Blood Sugar

Over the past year I've been tracking the searches that bring people to my web site What They Don't Tell You About Diabetes and have found that the single most popular search that brings in visitors is "What is a normal blood sugar?"

Much of my web site is devoted to answering that question with references to dozens of laboratory studies published in top peer reviewed journals which address various aspects of this question. If you want the details, that's the place to find them.

If you just want a quick answer to "What is a normal blood sugar?", here it is:

1. A normal fasting blood sugar (also the blood sugar you'd see before a meal) is 83 mg/dl (4.6 mmol/L) or less. Many normal people have fasting blood sugars in the mid and high 70 mg/dl (3.9 mmol/L) range.

2. A normal person eating the high carb typical American diet does not go over 120 mg/dl (6.6 mmol/L), ever, and many never go over 100 mg/dl (5.5 mmol/L).

3. A normal A1c is 4.6% or less. Heart attack risk starts to rise in a straight line fashion as soon as A1c goes over 4.6% and for each 1% of rise it is 2.3 times MORE frequent. That means that at a 5.7% A1c you have two and a third times more risk of a heart attack than a person has with an A1c of 4.6%

4. The reason that your doctor or lab might consider much higher numbers as "normal" is because there is a huge pool of people with undiagnosed diabetes and pre-diabetes in the "normal category" used by researchers in most studies because they used an arbitrarily chosen fasting plasma glucose of less than 110 mg/dl to define normal. An excellent study found that having a fasting blood sugar in the 90s was a very good predictor of diabetes 10 years or more down the road. So it is hard to defend it being truly normal.

5. People with diabetes CAN attain these normal blood sugar numbers. It takes the following to do it:

a. Education. You must learn how many grams of carb there are in every thing you eat, which includes weighing portions until you know what the "portion" listed in a Nutritional Information listing really looks like. Hint: It's MUCH smaller than you think. You need to learn in detail about what various drugs can and cannot do, and if you use insulin you must spend a lot of time reading about how to make it work. Bulletin boards and newsgroups are a good place to find people who have done this. Only take advice about how to get control from people with diabetes who have normal and near-normal blood sugars.

b. Cutting carbs. Carbs are what raise your blood sugar. Unless you are using insulin and are a genius at making it work, you are not going to be able to eat 100 grams of carbs a meal and control blood sugar. Somewhere between 12 and 30 grams a meal is the level most people with diabetes eat who maintain normal blood sugars.

c. Exercise. Some people find this helps greatly with blood sugar control. Others find it has no impact. It has a lot to do with what has made you diabetic. If it is mostly insulin resistance, exercise can usually help a lot. If it is insulin insufficiency, exercise is beneficial but won't necessarily normalize blood sugars on its own.

d. Meds. If you can't do it with carb restriction and exercise alone, it's time to check out drugs that lower insulin resistance, most notably Metformin.

3. Insulin. If diet and metformin don't do it, use insulin. Post-meal insulin works a LOT better for many of us than just Lantus, because Lantus can't bring down meal values to normal levels for most people. If you stress your beta cells at every meal, you are going to end up with non-normal blood sugars. It takes a lot of work and study to get insulin to where it gives you normal numbers. Most doctors can't be bothered and settle for numbers that won't keep you from developing complications. Read "Dr. Bernstein's Diabetes Solution" by Dr. Richard K. Bernstein to learn more about how to tailor insulin regimens so that they give you normal blood sugars.

That's it in a nutshell. Now get out there and get NORMAL!