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How To Control Blood Sugar Levels?
Question: sir
my brother in law is taking galvus met 50+1000 1 tab after break fast and after dinner along with Pioz 15 1 tab after breakfast. he is also taking glador 4 mg 1 tab before breakfast. for type 2 diabetics. his fasting sugar is within 80-90 but after 2 hours of food (whether after breakfast or after lunch or after dinner) the sugar level is always with range of 230-250. what is your advice on medicines he is taking. how can he reduce after food sugar level
my brother in law is taking galvus met 50+1000 1 tab after break fast and after dinner along with Pioz 15 1 tab after breakfast. he is also taking glador 4 mg 1 tab before breakfast. for type 2 diabetics. his fasting sugar is within 80-90 but after 2 hours of food (whether after breakfast or after lunch or after dinner) the sugar level is always with range of 230-250. what is your advice on medicines he is taking. how can he reduce after food sugar level
Brief Answer:
Add medications which decrease after food glucose
Detailed Answer:
Hi XXXXXX,
Welcome to HCM. I have gone through your question and understand your concerns.
How is his HbA1c (3 months average blood glucose)?
If only problem is increased after food plasma glucose 3 options are there
1. Diet control - frequent low calorie food 6-7 times a day. That is if he is taking 4 dosa for breakfast- decrease it to 3 and have a small snack at 10 am.
2. Add medicines that directly decrease after food glucose - like voglibose or acarbose. Your treating diabetologist will be knowing about this option.
3. Add bolus insulin with major meals.
You can suggest him to try these options after consulting with his treating doctor.
Hope I have answered your questions. If you have any further queries I will be happy to help you.
Regards,
Dr Ajish TP [MD,DM]
Consultant Endocrinologist
Add medications which decrease after food glucose
Detailed Answer:
Hi XXXXXX,
Welcome to HCM. I have gone through your question and understand your concerns.
How is his HbA1c (3 months average blood glucose)?
If only problem is increased after food plasma glucose 3 options are there
1. Diet control - frequent low calorie food 6-7 times a day. That is if he is taking 4 dosa for breakfast- decrease it to 3 and have a small snack at 10 am.
2. Add medicines that directly decrease after food glucose - like voglibose or acarbose. Your treating diabetologist will be knowing about this option.
3. Add bolus insulin with major meals.
You can suggest him to try these options after consulting with his treating doctor.
Hope I have answered your questions. If you have any further queries I will be happy to help you.
Regards,
Dr Ajish TP [MD,DM]
Consultant Endocrinologist
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Sir
you wanted to know his HbA1c (3 months average blood glucose). His HbA1c remains as 8.8 constantly for last 2 years. Therefore, kindly suggest your final medicine prescription for the whole day (apart from exercise and diat control) i.e before break fast, after breakfast, before lunch, after lunch, before dinner and after dinner. Many doctors are suggesting insulin instead of medicine. Do you also feel that diabetes can not be controlled with medicines?
regards
XXXXXXX
you wanted to know his HbA1c (3 months average blood glucose). His HbA1c remains as 8.8 constantly for last 2 years. Therefore, kindly suggest your final medicine prescription for the whole day (apart from exercise and diat control) i.e before break fast, after breakfast, before lunch, after lunch, before dinner and after dinner. Many doctors are suggesting insulin instead of medicine. Do you also feel that diabetes can not be controlled with medicines?
regards
XXXXXXX
Brief Answer:
It is better to start on insulin with this HbA1C
Detailed Answer:
Hi XXXXXXX,
I have noted the reports.
I understand your concerns.
May I make few things clear to you.
Our aim in treating diabetes is mainly to prevent diabetic complications (eye, heart, kidney, nerve and vascular diseases). If he develops complications the cost of treatment is going to increase very much and the quality of life will decrease. To bring down the complications we have kept some targets for sugar control :
1. HbA1C below 7%
2. Fasting sugar below 130 mg/dl
3. After food below 180 mg/dl
4. LDL cholesterol below 100 mg/dl
5. BP below 130/90 mm hg
Of which most reliable and important one is Hba1C - Which very high in your case. That means the risk of complications is around 60-80% high with this HbA1C.
The treatment whether it is medications, insulin or alternative medicines should be able to bring down HbA1C to 7%. So whether he is on drugs or insulin next HbA1C should be below 7%.
If we look at your brother in law's medications he is actually on 3 medications
Galvus (vildagliptin) - maximum dose is 50+50
Met (Metformin) - Maximum dose is 2500 - he is on 2000 mg/day
Glador (glimipride) 4 mg - maximum dose is 8, but we rarely go beyond 6 mg
So he is on fairly good dose of 3 anti diabetic medication. There is no point in increasing the dose of medications. That is the reason why I have offered insulin as an option.
If he still prefers oral medications, what I suggest is to take Voglibose (available as 0.2 mg tablets) three times a day along with 3 major meals. This medication can be started after consulting your doctor. He can continue taking other medications already on.
Please follow strict dietary modifications and exercise. We can repeat an HbA1C after 2 months. If it is not coming down, I think we should start him on Insulin rather than wasting time on oral drugs.
Regards
Dr Ajish TP
Consultant Endocrinologist
It is better to start on insulin with this HbA1C
Detailed Answer:
Hi XXXXXXX,
I have noted the reports.
I understand your concerns.
May I make few things clear to you.
Our aim in treating diabetes is mainly to prevent diabetic complications (eye, heart, kidney, nerve and vascular diseases). If he develops complications the cost of treatment is going to increase very much and the quality of life will decrease. To bring down the complications we have kept some targets for sugar control :
1. HbA1C below 7%
2. Fasting sugar below 130 mg/dl
3. After food below 180 mg/dl
4. LDL cholesterol below 100 mg/dl
5. BP below 130/90 mm hg
Of which most reliable and important one is Hba1C - Which very high in your case. That means the risk of complications is around 60-80% high with this HbA1C.
The treatment whether it is medications, insulin or alternative medicines should be able to bring down HbA1C to 7%. So whether he is on drugs or insulin next HbA1C should be below 7%.
If we look at your brother in law's medications he is actually on 3 medications
Galvus (vildagliptin) - maximum dose is 50+50
Met (Metformin) - Maximum dose is 2500 - he is on 2000 mg/day
Glador (glimipride) 4 mg - maximum dose is 8, but we rarely go beyond 6 mg
So he is on fairly good dose of 3 anti diabetic medication. There is no point in increasing the dose of medications. That is the reason why I have offered insulin as an option.
If he still prefers oral medications, what I suggest is to take Voglibose (available as 0.2 mg tablets) three times a day along with 3 major meals. This medication can be started after consulting your doctor. He can continue taking other medications already on.
Please follow strict dietary modifications and exercise. We can repeat an HbA1C after 2 months. If it is not coming down, I think we should start him on Insulin rather than wasting time on oral drugs.
Regards
Dr Ajish TP
Consultant Endocrinologist
Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
Sir
many thanks for your quick and long advice. This is my last question. Infact my brother in-law has visited his doctor today. The concerned doctor has changed the medicine. My brother in law was also having earlier high TG and Cholestrol. But TG and Cholestrol is under control with medicine. Recently my brother in law has done whole body check up. Kidney, heart and eye all are perfect except high sugar after food and Hb1AC as mentioned to you earlier. The recent test showed HDL 42 and LDL 70. BP 120/80, TG 150, Cholestrol 148. However sugar is passed in urine to some extent. Actually my brother in law is suffering from diabetics for last 8 years. The medicine today changed by the doctor is given below:
1. Before Breakfast : Glycomet GP 3/850 > 1 Tab
2.After Breakfast: Cardace 5mg> 1 Tab
3. During Lunch: Vingose 0.3mg > 1 Tab
4. After Lunch : Janumet XR(CP) Pack with two Tabs (One big and one small)
5. Before Dinner: Glycomet GP 3/850 > 1 Tab
6. During Dinner : Vingose 0.3mg > 1 Tab
7. Diatall D > Vitamin 1 Tab
Sir, Kindly see :
a) whether the present medicine prescribed by the doctor is O.K. and not over dose. If not, any alterations do you suggest?
b) Whether the above medicines are having any side effects/complications
I also read from the internet that oral medicines taken for a long time will destroy the beta cell of the body resulting in drying up the existing insulin available in the body and injecting insulin to the body from outside will be required in fiuture. So shall my brother inlaw try the above new medicines for a month and if the sugar level is not controlled then go for insulin.
Sir, finally I solicit your kind and detail advice again.
regards,
XXXXXXX
many thanks for your quick and long advice. This is my last question. Infact my brother in-law has visited his doctor today. The concerned doctor has changed the medicine. My brother in law was also having earlier high TG and Cholestrol. But TG and Cholestrol is under control with medicine. Recently my brother in law has done whole body check up. Kidney, heart and eye all are perfect except high sugar after food and Hb1AC as mentioned to you earlier. The recent test showed HDL 42 and LDL 70. BP 120/80, TG 150, Cholestrol 148. However sugar is passed in urine to some extent. Actually my brother in law is suffering from diabetics for last 8 years. The medicine today changed by the doctor is given below:
1. Before Breakfast : Glycomet GP 3/850 > 1 Tab
2.After Breakfast: Cardace 5mg> 1 Tab
3. During Lunch: Vingose 0.3mg > 1 Tab
4. After Lunch : Janumet XR(CP) Pack with two Tabs (One big and one small)
5. Before Dinner: Glycomet GP 3/850 > 1 Tab
6. During Dinner : Vingose 0.3mg > 1 Tab
7. Diatall D > Vitamin 1 Tab
Sir, Kindly see :
a) whether the present medicine prescribed by the doctor is O.K. and not over dose. If not, any alterations do you suggest?
b) Whether the above medicines are having any side effects/complications
I also read from the internet that oral medicines taken for a long time will destroy the beta cell of the body resulting in drying up the existing insulin available in the body and injecting insulin to the body from outside will be required in fiuture. So shall my brother inlaw try the above new medicines for a month and if the sugar level is not controlled then go for insulin.
Sir, finally I solicit your kind and detail advice again.
regards,
XXXXXXX
Brief Answer:
Take medicines as prescribed and follow up
Detailed Answer:
Hi XXXXXXX,
Nice structured question. I will explain in detail as you like long answers.
Your doctor has nicely stepped up his medications.
1. Regarding medications:
Now this is the maximum dose of medication he can be on.
Januvia - 100 mg/day, Metformin - 2700 mg/day, Glimipride 6 mg/day, Voglibose 2 tablets per day.
Only addition in medication now possible is to increase Voglibose to thrice daily (add one tablet with breakfast also).
So inform him that this is the maximum possible with oral medications. Tighten his diet and exercise. If sugars go wrong at anytime from now on, he has to be on insulin.
This medications prescribed by your doctor are not in over dose.
2. Side effects:
Side effects are many with medications. The common one usually seen in practice are:
Metformin : Gastric irritation, diarrhoea, vitamin B12 deficiency
Januvia : pancreatitis
Voglibose : Gastritis, abdominal distension
Glimipride : hypoglycaemia
3. Oral medications and insulin
What you learned from internet in this occasion is true. What the medication do is to squeeze insulin out of pancreas. This will result in beta cell exhaustion and failure of insulin production in future.
This effect is more with glimipride > metformin > voglibose > Januvia. But the power to reduce the blood glucose is also in same order. So we cannot skip glimipride.
In my practice I start with januvia and metformin followed by glimipride in diabetic patients. When the sugars are not getting controlled with 4 mg of glimipride, I will start them on once daily insulin. I will not wait till all my oral medications fail. This will improve there diabetic control. But some patients are so afraid of insulin pricks and in them my approach is to increase medications as your doctor has done.
Still no need to worry if his kidney and eyes are normal. He can wait for 1 month and start on insulin if needed.
Regards
Dr Ajish TP
Consultant Endocrinologist
Take medicines as prescribed and follow up
Detailed Answer:
Hi XXXXXXX,
Nice structured question. I will explain in detail as you like long answers.
Your doctor has nicely stepped up his medications.
1. Regarding medications:
Now this is the maximum dose of medication he can be on.
Januvia - 100 mg/day, Metformin - 2700 mg/day, Glimipride 6 mg/day, Voglibose 2 tablets per day.
Only addition in medication now possible is to increase Voglibose to thrice daily (add one tablet with breakfast also).
So inform him that this is the maximum possible with oral medications. Tighten his diet and exercise. If sugars go wrong at anytime from now on, he has to be on insulin.
This medications prescribed by your doctor are not in over dose.
2. Side effects:
Side effects are many with medications. The common one usually seen in practice are:
Metformin : Gastric irritation, diarrhoea, vitamin B12 deficiency
Januvia : pancreatitis
Voglibose : Gastritis, abdominal distension
Glimipride : hypoglycaemia
3. Oral medications and insulin
What you learned from internet in this occasion is true. What the medication do is to squeeze insulin out of pancreas. This will result in beta cell exhaustion and failure of insulin production in future.
This effect is more with glimipride > metformin > voglibose > Januvia. But the power to reduce the blood glucose is also in same order. So we cannot skip glimipride.
In my practice I start with januvia and metformin followed by glimipride in diabetic patients. When the sugars are not getting controlled with 4 mg of glimipride, I will start them on once daily insulin. I will not wait till all my oral medications fail. This will improve there diabetic control. But some patients are so afraid of insulin pricks and in them my approach is to increase medications as your doctor has done.
Still no need to worry if his kidney and eyes are normal. He can wait for 1 month and start on insulin if needed.
Regards
Dr Ajish TP
Consultant Endocrinologist
Note: For further follow-up, discuss your blood glucose reports with our diabetologist. Click here.
Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
Answered by
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