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Diabetes Developments - A blog on latest developments in diabetes by David Mendosa

Metformin Forever

May 30th, 2012 · 16 Comments

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Metformin controls the insulin resistance of people who have type 2 diabetes so well that, if possible, all of us should be taking it. That’s what Roderic Crist, M.D., told me at the annual convention of the American Society of Bariatric Physicians in Denver this weekend. Dr. Crist specializes in family medicine in Cape Girardeau, Missouri.

“Not everybody can take every drug,” he added, when I followed up our conversation by calling him at his office after he returned home. “But most of the time people can take metformin if they take it carefully.”

Doctors increasingly prescribe it not only for type 2 diabetes but also for insulin resistance, polycystic ovary syndrome, and non-alcoholic fatty liver disease.

Roughly one-third of Dr. Crist’s patients have diabetes. Well over half, if not two-thirds of the people he sees are insulin resistant.

“I treat insulin resistance with that drug even if they aren’t fully diabetic.” he says. “If they have high triglyceride levels and low HDL levels, particularly if they are centrally obese, they should probably be on metformin. It helps slow the progression of the disease from one thing to the next.”

But he goes further. He prescribes metformin to almost all of his patients who have type 2 diabetes — no matter how low their A1C level is. And he tells his patients that their levels should be 5.0 or less — not the American Diabetes Association’s less stringent recommendation of 7.0 or less. “If their A1C is at 5, their diabetes is in complete remission. So I have that as a goal.”

And he still prescribes metformin to them after they reach that goal. “The two important issues are that it will prevent progression and it should be used in the earliest phases of insulin resistance. We vastly underutilize metformin.”

But he has a concern about the usual starting dose of metformin. “When most physicians prescribe metformin, they start way too high,” he told me. “Almost all medications have side effects. For metformin the typical recommended dose is 500mg twice a day. They teach almost all of us physicians to do that and to increase it fairly rapidly to 850mg and then to 1,000mg twice a day. And almost all people who do that have GI side effects, typically nausea and diarrhea.”

He recommends that we go much, much slower. “Start with 250mg perhaps for a week,” he says. “And the second week to 250mg twice a day, and the third week to 500mg in the morning and 250mg at night, and the fourth week 500mg twice a day. And keep increasing at that rate very slowly, with the ultimate goal of 850mg twice a day or 1,000mg twice a day, depending on your needs. In this fashion you will rarely have side effects.”

Furthermore, when you go off metformin for one reason or another and then go back on it, you need to follow the same slow course. “You have to start this whole process all over again — even if you go off metformin for just a few days,” he says. “Taken correctly, it is far more well-tolerated.”

He also prescribes other medications to essentially all of his patients who have diabetes. He says that he follows the recommendations for doctors to prescribe either ACE inhibitors (angiotensin-converting-enyyme inhibitors) or ARBs (angiotensin II receptor blockers) to everyone who has diabetes to protect their kidneys, unless they have low blood pressure.

Is there a third drug that everyone with diabetes should take? I asked Dr. Crist.

“That’s a tough one,” he replied. “Perhaps aspirin, if there are no contraindications. Generally 81mg, but if you want to cover the entire spectrum of clotting disorders, perhaps two baby aspirin. I usually have most of my patients on aspirin, unless there is a contraindication.”

I am still considering whether to follow Dr. Crist’s advice to go back on metformin. I did decide to again take a baby aspirin every day. All of his recommendations are certainly provocative and well worth our careful attention.

Metformin helps people with type 2 diabetes to control the amount of glucose in our blood. It decreases the amount of glucose we absorb from our food and the amount of glucose made by our liver. Metformin also increases our body’s response to insulin, a natural substance that controls the amount of glucose in the blood.

Metformin is one of the most effective of our diabetes medications, one of the safest, and now that generic forms are available is the least expensive. For several excellent reasons it is the most widely prescribed diabetes drug in the world.

This is a mirror of one of my articles that Health Central published. You can navigate to that site to find my most recent articles.

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Posted in: Diabetes Medication

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16 responses so far ↓

  • 1 Anna // May 30, 2012 at 6:58 am

    Hi David, thank you for this very thorough point of view. One thing that has made me hesitate to take metformin is that I have heard anecdotally that the medication loses its effectiveness over time. Since I am still at an early stage of diabetes, I feel as if I should wait it out until absolutely necessary. Do you think the effectiveness of metformin ‘wears off’, or is it that the diabetics who experienced this had a worsening of the disease as a matter of course, and couldn’t tell the difference?

  • 2 David Mendosa // May 30, 2012 at 9:15 am

    Dear Anna,

    Two good theories, but I think a third one is the answer. I do not think that the effect of metformin wears off and I certainly don’t think that diabetes is naturally a progressive disease (as I have written elsewhere). But it does get progressively worse when we don’t manage it well. And we don’t manage it well by following the lax guidelines that the “experts” say to follow. When we manage our diabetes, like with an A1C level always below 5.5 or so, we don’t get complications. So, please rethink your idea to “wait until absolutely necessarily.”

    David

  • 3 Arun Prabhu // Jun 1, 2012 at 9:45 am

    David, has there been any conclusive evidence or study to show that an A1C below 5.5 is the right figure to prevent any complications?

  • 4 David Mendosa // Jun 1, 2012 at 12:00 pm

    Dear Arun,

    The two biggest studies ever, the Diabetes Control and Complications Trial or DCCT, and the United Kingdom Prospective Diabetes Study or UKPDS, both established that as A1C levels rise above normal the risk of complications increase dramatically. That is not to say that we can be absolutely sure that any level “is the right figure to prevent any complications.”

    David

  • 5 Sharon // Oct 10, 2012 at 3:28 pm

    When my former doctor diagnosed me as diabetic based on the so called metabolic syndrome, my A1C was 6.2. Since then I’ve taken Metformin for many years & maintained my A1C at around 6.0. I had no apparent side effects & my weight dropped from 170 lbs. to 130lbs. Recently I was having various unrelated health problems, including pneumonia, but was found to have critically high lactic acidosis, a rare side effect of Metformin. I no longer take anything for diabetes, as my daily numbers show. My arms & legs still ache all the time,especially the left side. Don’t know what to do now.
    My current doctor doesn’t seem to think my numbers are that bad & thinks an A1C of 7.0 is fine.

  • 6 David Mendosa // Oct 10, 2012 at 3:35 pm

    Dear Sharon,

    What a shame that you got lactic acidosis. You are right that is a rare side effect of metformin, which does have a black-box warning that it can cause that. But you are the only person I have ever heard of that it affected. I wonder if that caused your arms and legs to ache? If so, that will probably resolve itself. Still, if I were you, I would concentrate on improving my diet and vitamin/minteral intake and also work with a doctor to see if it could have another cause.

    Best regards

    David

  • 7 Sharon // Oct 11, 2012 at 9:53 am

    Diet alone hasn’t worked for me. Morning fasting numbers usually very high. Take vitamin d & fish oil. Often other supplements have caused problems. Don’t eat junk or fried foods & don’t want to lose any more weight.

  • 8 Priya // May 6, 2013 at 6:21 pm

    Hi,
    My husbands blood sugar rose very high due to change in place and stress. Hba1mc went upto 120. He is 40. He is on 3 metformins 500 g daily. But fasting sugars still seem to be high around 10-11. He takes oats fur breakfast, salad for lunch and some carbs and curry for dinner. He has a busy working schedule which involves walking. What else should we do. Is there anything we need to add or cut down?

  • 9 David Mendosa // May 6, 2013 at 7:26 pm

    Dear Priya,

    Good question. It is the carbs that he is eating and only the carbs that make his blood sugar level go up. That includes the oats and particularly whatever grains, like bread, pasta, and rice that he may be eating. The fewer the carbs he eats the better his blood sugar will be.

    Namaste,

    David

  • 10 liz greene // Aug 4, 2013 at 10:22 am

    I am using metform in a compounded form,
    in a vanishing cream base. I have been unable
    to tolerate taking it orally because of the GI
    side effects, even starting with tiny doses
    125 mg. at a time. People with PCOS have been
    using the drug compounded this way for several
    years. It works for me, and there are NO SIDE EFFECTS–it doesn’t go thru the gut at all,
    just thru your skin into your circulatory system. I’m using 50 mg. per 1 ml of cream,
    3x/day (three applications on each forearm
    over the day, for a totel of 300 mg. per day).
    May have to up the dose one more time, but
    it definitely knocks down blood sugars.

    Big drawback is that Medicare won’t pay for
    it and a 1 month supply is currently costing
    me $287.00 (ouch). But I will keep paying
    for it myself if I must.

    I found the information on compounding it
    thru one of the websites on PCOS–there’s an article called Metformin Without the Misery.

    Be curious to know what you think about this.

    Liz

  • 11 liz greene // Aug 4, 2013 at 10:26 am

    I am using metform in a compounded form,
    in a vanishing cream base. I have been unable
    to tolerate taking it orally because of the GI
    side effects, even starting with tiny doses
    125 mg. at a time. People with PCOS have been
    using the drug compounded this way for several
    years. It works for me, and there are NO SIDE EFFECTS–it doesn’t go thru the gut at all,
    just thru your skin into your circulatory system. I’m using 50 mg. per 1 ml of cream,
    3x/day (three applications on each forearm
    over the day, for a totel of 300 mg. per day).
    May have to up the dose one more time, but
    it definitely knocks down blood sugars.

    Big drawback is that Medicare won’t pay for
    it and a 1 month supply is currently costing
    me $287.00 (ouch). But I will keep paying
    for it myself if I must.

    I found the information on compounding it
    thru one of the websites on PCOS–there’s an article called Metformin Without the Misery.

    Be curious to know what you think about this.

    The article I read on this is in diabetes self management, http://www.diabetesselfmanagement.com/
    blog/David-Sper0/metformin

    Liz

  • 12 David Mendosa // Aug 6, 2013 at 11:49 am

    Dear Liz,

    I am not familiar with taking metformin topically. But I do know that many people stop using metformin orally because of the gastric side effects. That, however, is only because their doctors don’t tell them to build up the dosage very very slowly (they call this to titrate the dose). I would hope that you could try it again this way. Please read my article headed “Metformin Forever.”

    Namaste,

    David

  • 13 Susan Schneider // Jan 12, 2014 at 2:22 pm

    Hi David: I was diagnosed with Type II 5 years ago, and have been under great control since, but have had HORRIBLE explosive metformin induced diarrhea around 11 am every day until a month ago. My father who is turning 90 is an internist, and was just also diagnosed with Type II, and had the same side effect. However, he suddenly recalled he had learned in medical school (Northwestern Medical School ‘45 in Chicago) that if a drug causes diarrhea, take the cure for it at the same time you take that medicine. So I am now taking a 1 mg. Imodium tablet with my a.m. Metformin, and suddenly I am diarrhea free for the first time in 5 years. I suppose it would have been helpful if someone had mentioned this 5 years ago. Neither my nephrologist or GI guy knew this trick. Thought you might know how to get it out to the right people. Thanks for your great columns and website! Susan Schneider

  • 14 David Mendosa // Jan 12, 2014 at 6:08 pm

    Dear Susan,

    Thanks for sharing. That is certainly one way to manage using metformin if your stomach can’t tolerate it. Of course, some people have no problem with it, and I never did when I used it.

    Namaste,

    David

  • 15 Juanita W // Jan 20, 2014 at 9:11 pm

    I went on the Atkins diet eating lots of good veggies, for two weeks, without cheating and stopped taking insulin (was on levemir 25 units 2x a day ), my fasting glucose kept running from 145 to 175…..even when carbs were 20 grams or less a day!!! Only lost 4 pounds in two weeks. Can it be done….to stay off insulin….and control D? I do take 1000 metf 2x per day. I’m 71.

  • 16 David Mendosa // Jan 20, 2014 at 9:25 pm

    Dear Juanita,

    You are right that your level was too high for the very low-carb diet you were following. The only thing that I can think of is that you have type 1 diabetes or at least very few beta cells. Still, anyone who has type 1 can reduce their insulin on a very low-carb diet.

    Namaste,

    David

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