April 26, 2007

Byetta, Januvia and Insulin

Since I posted my blog entries on Januvia, and the associated page on my site, "What They Don't Tell You About Diabetes" I've received a lot of email from people who would prefer to take Januvia rather than Byetta and want to know my opinion about which is best.

My suspicion is that if you have found that you respond strongly to a relatively low dose of a sulfonylurea drug such as Amaryl or glipizide (the sulfonylurea drug found in Glucovance) you may respond strongly to Byetta and possibly Januvia, though everything I'm hearing suggests that far fewer people respond to Januvia than Byetta.

If you have no response to these drugs, it may indicate that you've gone past the point where stimulating your beta cells with any drug is going to produce insulin because you no longer have enough functioning beta cells left to respond to beta cell stimulation.

Januvia, if its safety concerns are addressed, may turn out to be the drug of choice for people with prediabetes or forms of diabetes in which fasting blood sugar is still fairly well controlled and loss of post-meal blood sugar control is the main problem.

However, what disturbs me is that I hear from far too many people who are walking around with dangerously high blood sugars who inquire about Januvia because they hope they can add another pill to their regimen in order to avoid going on insulin. This is a tragically misguided approach.

Insulin always works. For everyone. These newer drugs work only for some people and many times they do not lower blood sugars anywhere near a healthy level. I am disturbed by the number of doctors who, based on postings on the Byetta blog, are putting patients on Byetta who have blood sugars well over 250 mg/dl after meals. This is a level known to cause blindness, kidney failure, amputation and heart attack death. Most of the time, after taking Byetta for several months, these patients still do not have blood sugars that are anywhere near the complication-avoiding level of under 140 mg/dl at 2 hours which is recommended by the endocrinologists who make up the American Association of Clinical Endocrinologists.

In the old days, doctors defended not putting their patients on insulin saying the patients wouldn't take shots. Well, taking Byetta involves taking two shots a day and unlike insulin, Byetta shots can sting and often puff up into insect-like weals. Two shots a day of insulin, properly dosed could bring the blood sugar of these people down to a safe level. Byetta, which costs more than twice as much, does not.

So if you are already on a lot of oral medication and are still going over 250 mg/dl after meals, you probably should start out with insulin, get your blood sugars down to a safer, more manageable level to save whatever functioning beta cells you still have left, and then see if Byetta or Januvia can improve matters for you.

Neither of these drugs will help if your beta cells are dead, and the research we cite on our Organ Damage page makes it clear that prolonged exposure to blood sugars over 150 mg/dl kills beta cells dead. Only insulin, dosed properly, is 100% guaranteed to lower blood sugar.

Even scarier are the patients who report they are on insulin but are still getting extremely high blood sugars especially after meals. Clearly they are on a "one size fits all" insulin regimen that does not take into account their carbohydrate intake or their personal level of insulin resistance.

These regimens (many involving 70/30 insulin mixes) should be totally discredited by now, because they don't give good enough blood sugar control, but they are still used by many family doctors who were trained a decade ago or longer and are not well educated in how to use modern insulin. Some of these people,too, are on Basal insulin alone when they need meal-time insulin to control their dangerously high post-meal blood sugar spikes.

If you are on insulin and still getting very high blood sugars, you need to do two things. One is to read "Jennifer's Advice to Newbies" and try out Jennifer's advice for a month.

If that doesn't help, you must find a doctor who will work with you to find an insulin regimen that does control your blood sugar. When you've got your blood sugars under pretty good control, then you can start fooling around with new and experimental drugs. But the time to do that is when you aren't going into the over 200 mg/dl red zone after every meal!


BobT said...

What about taking Chromium Picolinate after eating? I have tried it and it drops my blood sugar to around 130.


Jenny said...

I discuss supplements in an article on my main web site, http://www.phlaunt.com/diabetes.

Chromium is one that some people find helpful, others find useless. It's worth a try. There is some question about its safety. The evidence goes back and forth on whether it can cause cancer and there isn't a 100% solid answer on this.

Διώνυσος said...

Insulin is not the answer for many type 2s remember reducing blood pressure control and lipids give more reduction in cardiovascular mortality and morbidity than Hba1c reduction. Insulin maybe the only treatment but it id FAR from prefect due to increasing insulin resistance and weight gain

Jenny said...


Insulin dosed properly does NOT have to increase insulin resistance or cause weight gain. When it isn't carefully titrated to carb intake, and when people are told to eat huge amounts of carbs to balance the generic doses of insulin, yes, weight gain occurs.

There is NO evidence that reducing A1c TO NORMAL LEVELS is less effective than reducing lipids or BP because no study has ever tried to do this.

In the Low Carb diet studies, they found BP and lipids dropped as a side effect of cutting carbs (as did blood sugar) but all studies where people with diabetes "lower A1c" they lowered it to 7% which still meant they were dangerously high and also that they were eating a lot of carbs, since these studies were done when doctors recommended low fat/high carb diets to people with diabetes.

Unknown said...

Insulin does nto ALWAYS work, for everyone. I soent a year on Lantus and did not achieve the blood sugars I needed to. I am extremely insulin resistant. The longer I go without eating, the higher ny blood sugar is. My fasting sugars are deadly. I was in the hosp once, on an inuslin drio and my blood sugars continued to rise while the endo stood there saying "this is not supposed to happen"

Jenny said...


Insulin DOES always work for everyone. You should see a university-affiliated endocrinologist with experience in treating severe insulin resistance.
They can put you on U-500 R and work with you to find the dose that is effective.

You may be insulin resistance or there is some chance you have developed insulin antibodies. In any case, there are ways of treating your problem. I have heard from people with the same problem who have improved greatly once they found a doctor with the specialist training needed to handle this.