Brief Answer:
Dose adjustment of medicine may be helpful.

Detailed Answer:
Hi Mr. XXXXXXX XXXXXXX
After going through your question it is obvious that there is good reduction in HbA1c level after diagnosis (8.2 to 6.2), though there is recent rise in HbA1c level (6.2 to 6.8).
In your case there is definite scope for further reduction in HbA1c level.

First I want to discuss about your concern regarding low and high blood sugar levels-
- From your blood sugar chart it is clear that you had low blood sugar levels mainly before lunch and before dinner (value ranging between 70 - 80)
- I want to know- Are there any symptoms of low blood sugar (hypoglycemia) at the time of low sugar values like sweating, palpitation, restlessness, headache, dizziness, unusual hunger, disorientation, loss of consciousness in more serious cases?
- If there are no symptoms of hypoglycemia I would not be so concerned about those low readings. Only issue is you should know about hypoglycemia (symptoms of hypoglycemia, what need to be done during episodes of hypoglycemia) you can discuss it with your doctor.
- Your high blood sugar readings are mainly after lunch and after dinner, these high readings can be tackled with dose adjustment of different medicines that you are taking.

Now I want to discuss about your medicine-
You are on three different types of medicines that have different mechanism of action-
1) Metformin (your daily dose is 500mg)
2) Gliclazide (your daily dose is 80mg)
3) Sitagliptin (your daily dose is 25mg)

- Out of these three medicines Metformin and sitagliptin when used alone or in combination with each other rarely cause hypoglycemia.
- Sitagliptin mainly control after meal blood sugar levels (after breakfast, after lunch, after dinner)
- Gliclazide usually has longer duration of action and control before meal blood sugar levels along with some effect on post meal sugar levels.
- Gliclazide may cause hypoglycemia (when used alone or in combination with other medicines) with over dose (as in initial phase of treatment of diabetes where dose adjustment of medicine requires some time), missed meals.

If similar scenario would have present in my patient, I would have increased the doses of metformin and sitagliptin to maximal acceptable dose (depending upon patient's age, kidney and heart status) and would have reduced the dose of Gliclazide or would have stopped Gliclazide depending on blood sugar levels.

However I will advise you to consult your treating doctor for better dose adjustment that are suitable to you depending on your kidney and heart status and for further evaluation if needed.

Hope this may have clarified your queries.
If you have any further question I will be happy to help.

Regards,
Dr. Abhay Mali
Diabetologist

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Brief Answer:
Maximizing the doses of metformin and sitagliptin may be helpful.

Detailed Answer:
Hi Mr. XXXXXXX XXXXXXX
Thanks for your appreciation.

First I want to discuss the action of Metformin:
- Metformin is the first line drug for the treatment of Type 2 diabetes.
- It decreases the insulin resistance (basic pathology of Type 2 diabetes).
- Insulin resistance means different body organs (mainly liver, fat tissues and muscle) requires extra insulin for glucose utilization that is there is resistance to action of insulin at tissue level. In the initial stages of insulin resistance pancreas can produce extra insulin to compensate the need of extra insulin by different organs but as time passes pancreas cannot produce adequate insulin and body cannot utilize glucose in blood and blood sugar start rising (that is there is development of diabetes).
- Metformin mainly act on liver with some action on muscles. And Mainly decreases before meal sugar levels with some effect on post meal blood sugar level.

If similar scenario would have present in my patient with normal kidney function and without any heart disease I would have prescribed following medicines to him.
1) Tablet containing combination of metformin with sitagliptin (500mg+50mg) two times a day 1 tablet before breakfast and 1 tablet before dinner.
2) Tablet containing metformin 850mg 1 tablet after lunch.
With regular blood sugar level monitoring.
There are very rare chance of hypoglycemia with this combination.
Though there may need for further dose adjustment or addition of different medicine in future depending on blood sugar levels and HbA1c level.

As these are prescription medicines you need to discuss it with your treating doctor or any other local diabetologist.

Healthcare magic provide provision for direct question on the name of particular doctor.

I hope this information would have clarified all of your queries.
If so, close the discussion and rate the answer.
Feel free to ask more questions in future.

Regards,
Dr. Abhay Mali
Diabetologist.

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Brief Answer:
Your blood sugar target should be as close to normal individual.

Detailed Answer:
Hi Mr. XXXXXXX XXXXXXX
XXXXXXX Diabetes Association (ADA) recommendation for glycemic control is -
* HbA1c <7.o%
* Premeal capillary plasma glucose level 80-130mg/dl.
* Peak post meal capillary plasma glucose level < 180mg/dl.
Though ADA also recommend that blood sugar level goal should be individualized based on duration of diabetes, age & life expectancy and associated comorbid conditions.

After knowing your duration of diabetes (~1year), medications of diabetes, previous good blood sugar control I will advise following glycemic goals for you-

* HbA1c as close to normal as possible 6-6.5%
* Premeal capillary plasma glucose level 70-110mg/dl.
* Peak post meal capillary plasma glucose level < 160mg/dl.
* Random capillary plasma glucose level < 180mg/dl.

capillary plasma glucose means blood sugar done by using glucometer.

Hope this information is useful to you.

Regards,
Dr. Abhay Mali

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