Metformin beyond it’s blood sugar lowering properties

 

The flower is of course,the French lilac or goat’s rue,the original source of that well known anti-diabetic drug Metformin. Believed to be the most widely prescribed diabetes drug in the world,it was introduced into Britain in 1958 but not licensed for use in T2 diabetes in the US until 1994.

It works by blocking the production of glucose in the liver and also by helping the body to utilise insulin properly.
It appears to be most effective in helping with weight loss and thus reducing insulin resistance. This effect is not maintained at the same rate after the initial period of weight loss and treatment, but many patients, including those not overweight at diagnosis ,continue to take it for the cardiovascular protection it is said to  afford. Although this cardiovascular protection, appears to be generally accepted; there does not appear to be conclusive proof. See below *
Reappraisal of Metformin Efficacy in the Treatment of Type 2 Diabetes: A Meta-Analysis of Randomised Controlled Trials  PLOS Medicine
This showed no evidence that metformin has any beneficial effect on all-cause mortality, on cardiovascular mortality, or on cardiovascular morbidity among patients with type 2 diabetes. These findings must be cautiously interpreted because only a few randomized controlled trials were included in this study, and only a few patients died or developed any cardiovascular illnesses. Importantly, however, from these findings, it is impossible to exclude beyond reasonable doubt, the possibility that metformin causes up to a 25% reduction or a 31% increase in all-cause mortality. Similarly, these findings cannot exclude the possibility that metformin causes up to a 33% reduction or a 64% increase in cardiovascular mortality. Given that a large number of patients take metformin for many years as a first-line treatment for diabetes, further studies are urgently needed to clarify this situation.
T2s and some T1s and other types may be prescribed metformin, as also – pre-diabetics, those suffering from polycystic ovary syndrome, and Gestational diabetes. It is also used in the treatment of nonfatty liver disease. Some studies appear to suggest that it can protect against certain cancers-mainly those to which diabetics appear to be more susceptible. This is very exciting and appears quite feasible  in the light of recent discoveries re sugar and insulin markers and receptors  but a great deal more needs to be done before this view can be substantiated.  The meta analysis=http://journals.sfu.ca/ijmbs/index.php/ijmbs/article/download/330/696will be of interest to those who are interested in the current thinking about this drug.
There are many studies concerning various aspects of metformin therapy, but the meta analyses referred to here are the most recent.*
*Metformin is accepted as the first line drug of choice, where diet and exercise and other lifestyle changes, are not sufficient to reduce blood glucose levels. There are of course contraindications. Metformin is not suitable for everyone. It is not currently prescribed to those with renal impairment or heart failure. Mainly because of the role it is thought to play in the development of Lactic acidosis – see below in ’side effects.*
So what is the downside to this ‘wonder drug’? Most patients would cite the gastro-intestinal upsets which can last for some time.  Switching to the slow release version is the answer for most people although there are some who cannot tolerate it in any form. ‘Many studies will quote lactic acidosis as the worst side effect of metformin as it can be fatal.*patient.co.uk/doctor/Lactic-Acidosis.
The reputation of the biguanide metformin for causing lactic acidosis may be overstated, and largely based on experience with its more toxic predecessor phenformin. It can cause lactic acidosis in overdose, or if continued in severely ill diabetics who become dehydrated, but seems to be well tolerated on the whole, with many of the current cautions for conditions such as heart failure, probably being overzealous and denying a safe and useful therapy to many patients.[5] A Cochrane systematic review found no evidence of an association with lactic acidosis, or hyperlactataemia in study-based use.[6]
*Lactic acidosis is quite rare in any event, the usual figure quoted is less than 1 in 10,000.This seems quite reassuring, until one considers that the same figure is given for the side effects, which appears to be on the increase in some groups and which is often misdiagnosed. The real reason in fact for this post.
We are two T2 diabetics who have been on metformin for a number of years.  Both naturally slim-so metformin probably makes very little difference to our HbAIC’s and both have taken it mainly for the potential cardiovascular protection.
We are at an  age when we may not be able to absorb an important nutrient  from diet alone-some studies say this may be as low as age 50 although others estimate it as much later, and are concerned that we may be in danger of suffering Vitamin B12 deficiency.
It is very well documented that metformin use for an extended period, or in older age groups or at a high dosage can have this effect. The effects of Vit B12 deficiency can be serious if left untreated. It is also often misdiagnosed..
09 December 2013
Anaemia and anaemia caused by a lack of vitamin B12 can result in symptoms which include:
Extreme tiredness or fatigue
A lack of energy or lethargy
Being out of breath
Feeling faint
Headache
Ringing in the ears ( tinnitus)
Lack of appetite
More specific symptoms linked to a lack of vitamin B12 include:
Yellowing of the skin
Sore, red tongue
Mouth ulcers
Changes or loss of some sense of touch
Feeling less pain
Walking problems
Vision problems
Mood changes, irritability, depression or psychosis
Symptoms of dementia
Causes of vitamin B12 deficiency
 
Vitamin B12 deficiency is more common in older people and affects around one in 10 over 75s.
The most common cause of vitamin B12 deficiency is pernicious anaemia, an auto-immune condition that affects around one in 10,000 people. Pernicious anaemia is caused by a lack of a protein called intrinsic factor that’s needed to absorb vitamin B12 from food into the body from the gastro-intestinal tract. This condition is more common in people over 60, in women, in people with a family history of pernicious anaemia or some autoimmune conditions, including Addison’s disease and vitiligo.Vitamin B12 deficiency is risk for people who follow a strict vegan diet who don’t eat the major food sources of B12: meat, eggs and dairy products. Babies whose mums are vegetarians may have vitamin B12 deficiency.
Other causes of vitamin B12 deficiency include:
Atrophic gastritis, or thinning of the stomach lining
Stomach ulcers
Surgery to remove part of the stomach or small intestine
Digestive conditions such as Crohn’s disease, coeliac disease, bacterial growth or a parasite.
Medication, including proton pump inhibitors (PPIs) for indigestion
Diagnosis of vitamin B12 deficiency

Blood tests and examination of blood cells under the microscope assess haemoglobin levels, the size of red blood cells and the level of vitamin B12 in the blood. The levels of folate are also usually checked for the related condition folate deficiency anaemia.Once the diagnosis is confirmed, further tests may be carried out to try to find out what’s causing the anaemia.A referral may be made to a specialist, such as a haematologist for blood conditions, a gastroenterologist for digestive disorders or a dietitian for advice on eating food containing more vitamin B12.
The above does not mention metformin specifically but many other studies do.  Apparently up to 30% of metformin users go on to develop B12 deficiency. Misdiagnosis is common as Vit B12 deficiency can mimic several serious disorders.
Dementia—Alzheimer’s disease
Multiple sclerosis
Depression
Post-partum depression/psychosis
Bipolar disorder
Neuropathy (diabetic, CIDP)
Diagnosing and Treating Vitamin B12 Deficiency (video)

Vitamin B12 deficiency can sneak up on you, and can lead to a myriad of diseases and disorders. Know the signs and symptoms. You could be deficient yet still test in the so-called range of “normal B12” on a blood test, especially if you have taken an oral B12 supplement of uncertain quality, or you have been under-treating the deficiency. Oral B12 supplements do not work for all patients; patients with digestive/absorption problems benefit from B12 injections, as do patients with nerve damage.
*Conclusion

Despite the above and  recommendations from many studies over the years,  there is still no standard requirement or directive for routine testing for vitamin B12 deficiency  for long-term or high dosage metformin users  in the UK.
Diagnosis is fortuitous in many cases and this is a great pity because the condition is easily treated.
Universal screening is still not considered to be cost effective  but there is sufficient evidence, in our opinion, to justify routine testing of those on long term and/or high doses of metformin and of the elderly who cannot absorb sufficient B12 from their diet. Testing could easily be included with the blood tests for the annual review.
It would be worthwhile in order to raise awareness of possible Vit B12 deficiency for those on metformin who might by those at risk and aware of it raising the issue with their HCP and asking to be tested. It is not a question of causing extra expense to the NHS but of saving it by avoiding misdiagnoses and more costly treatment being required unnecessarily, where the condition mimics other disorders.
This is a serious matter and should be treated as such.  The mantra about metformin being safe and cheap and effective may be true, but it is not the whole story.
There are those like our own Paul and others, contributing to diabetes forums, who because they suffer from B12 deficiency, not caused by metformin, are yet able to recognise the symptoms in others and I am sure must have  been the means of helping many to a faster diagnosis.  If routine testing of certain groups is impossible, then it should be possible, surely, to include, in the annual review a few questions about possible symptoms as a marker for those who may require tests.
As the numbers diagnosed with diabetes continue to increase and as people live longer with the condition, this matter becomes more pressing and affects more people.
Please be aware of the risks for yourselves-diabetic or not-and help spread awareness of this potentially dangerous but easily treated condition.Kath & Graham
Posted in Big Pharma, Blood glucose, Living with diabetes, Type one diabetes, Type two diabetes | Tagged | 2 Comments

The British Dietetic Association a complete unprofessional shambles ?

From the British Dietetic Association website re a recent meeting of members.
“Carbohydrate Advice in Type 2 Diabetes – The ‘Hot Potato’ of  ! ! Dietetics?”
“The latest UK nutrition guidelines for diabetes suggest an individualised approach to carbohydrate in Type 2 diabetes, and focus on calorie reduction and weight management in those who need to lose weight. But where does that leave more detailed or specific advice about carbohydrate for individual patients? What should Dietitians be advising their patients? Preliminary research into the current practice of UK Dietitians in this topical field will be reported, together with the current evidence-base. Participants in this session will have the opportunity to review their own practice in this area and contribute to the ongoing debate.”
.

Diabetes care in the UK is abysmal for the majority of diabetics. The NHS audited annual statistics are grim, and they are grim year after year, no progress is being made, in fact the situation is getting worse. One of the keystones of good diabetes control is diet. And the experts on diet in the UK are the dietitians who are members of the British Dietetic Association. Recently they held a meeting and produced a survey conducted on some of their members opinions, some of the results you see below. As you can see their methods seem to be very unsound, in fact I don’t see any method at all. Clearly UK dietitians have no general guidelines or policy agreement to work to whatsoever. To the question How frequently do you advise carbohydrate restriction with type two diabetes on oral medication, sometimes was the answer for the most. The question what would be a realistic carbohydrate restriction in type two diabetes 30 to 50% of energy was the overwhelming reply.

The $64000 question is, how could any successful organisation operate with absolutely no overhaul common policy ? no corporate structure or method of operation whatsoever. Remember we are not talking about flogging nuts and bolts here, we are talking about the health of millions of people. Is it any wonder the UK diabetes statistics are so grim, when the very organisation that should be leading the way to better health for so many, could not run a whelk stall. Until the BDA at the very least, issue some basic guidelines to their members and have some sort of common policy, regarding carbohydrate control or restriction, the carnage will go on. It is my opinion, the BDA is at the very least partly responsible for the early death of countless diabetics. Will it be ever thus ?

Source of information http://www.bda.uk.com/BDAlive/Paul%20McArdle%20.pdf

Eddie

Posted in Diabetes news, Diet, Diet and dieting, Dietitians, Health politics, Uncategorized | 1 Comment

Dr.Troy Stapleton – I Manage My Type 1 Diabetes By Eating LCHF

Another must watch video. Low carb high fat not just for type two diabetics. Eddie

Posted in Blood glucose, Diet, Diet and dieting, Fats, Keto diets, Lipids, Low carb diet, Support for diabetics, Type one diabetes, Type two diabetes | 1 Comment

The Eyes have it Part 2

 

Following on with my two previous Eyes posts, namely. ‘The Eyes Have It – Introduction’ and ‘The Eyes Have it Part 1’. I now have another Part for you to read.Here is ‘The Eyes Have it Part 2’. These are my personal experiences and thoughts which I hope will be of interest and use to readers.

As an aside, thank you, for the comments and emails received with regard to my previous ‘Eyes’ posts. I know many readers have found them interesting and helpful.

When second and subsequent appointments are necessary at the hospital eye clinic the procedure may differ slightly as additional tests may have been requested by the Doctor. before you are seen again .

FIELD TEST
Part I referred to the Field of Vision test which may have been requested if pressures in the eyes appeared to be high or if there is a family history of glaucoma. In this case the patient may already have been tested by his/her own optician./ optometrist. The test used in my hospital is known as Automated Perimetry. This test evaluates your vision field by flashing random lights of different strength (generated by computer) in your peripheral vision field while your eyes are fixed on a source light straight ahead. The patient uses a button to indicate the presence of objects. There may be a blind spot if you fail to see objects in a certain portion of the visual field. This test requires the patient to be able to co-operate and concentrate and requires a certain amount of co ordination so is not suitable for everyone. There are other alternatives so don’t worry if there is a problem for you. I dislike this test because it appears to trigger my claustrophobia and makes my eyes water copiously.

A doctor I spoke to recently said that it was stressful because lights are shown which are outside the normal field of vision, and patients sense this is the case and feel anxious. because they have failed to register the flash. I don’t think it is ever taken as definitive in itself, – few tests are. It may be worth asking for it to be noted, however, if you have a headache or if your eyes are affected by hay fever or sinus problems. The Doctor will give you the result during your consultation.

OCT SCAN
It is also routine for an OCT scan to be requested. I have one almost every time I visit the eye clinic. OCT means Optical Coherence Tomography. This is a wonderful tool with many applications. It is a way of photographing cross sections of the retina in 3D, when used in ophthalmics. As well as its diagnostic uses it is also used to measure the success of various procedures and even indicate hazards which might occur in surgery. It can identify the areas where sub retinal fluid is present which means that injections or laser may be targeted more accurately in maculopathy and macular oedema.

The patient is asked to look into the camera. .Then it is just a matter of keeping the eyes wide open and not blinking while focusing on a central point for a few seconds. There is with the older machines a brief flash of light at the end but nothing else to disturb or alarm. Wheelchair users can remain in their wheelchairs for the scan. The results will be available on computer screens within minutes.

When I first began having regular OCT scans they were carried out by a skilled and experienced biometrist, then, a few years ago nurses were trained on the procedure. Some are excellent and there are no problems, but others find it challenging. Unless the image is clear it is useless. Occasionally the scan has to be repeated. The operator can examine the finished product and decide it is not good enough or the equipment senses that an error has occurred. I am so used to it all that I can tell with some accuracy when a retake is going to be necessary. It is usually because the focus wasn’t correct to begin with.

While searching for images I came across this in Netscape the American Ophthalmology magazine. Link here to article.

Also the images below show the scan in the top picture macular oedema while that underneath shows normal.

A very little experience, allows the patient to correlate the inconsistencies in vision apparent when tested on the standard eye chart with the images shown on the scans. Overlapping letters sloping and missing letters can all be matched to the irregularities on the OCT. I think my consultant is still trying to work out how I always know which eye is shown on the screen at any one time. I can only imagine the improvement in diagnosis and treatment which this amazing piece of technology has made possible while being so comfortable and non-invasive for the patient.

FUNDUS FLUORESCEIN ANGIOGRAPHY
The final test which may be advised for patients with diabetic eye disease is Fundus Fluorescein Angiogram commonly known as FFA [of course.] This procedure or the suggestion of it has been the cause of more anguish in my correspondence than any other. For a start to most people an angiogram means a coronary angiogram, they will never have heard it associated with eye problems. It is used to obtain more information about the blood vessels in the retina. It will show if there is leakage or bleeding and where treatment, if necessary, should be targeted. Patients – especially the newly diagnosed, are often terrified by the consent form they are asked to sign and the warnings they are given. The fact is that the dye used in this procedure, the fluorescein, yellow dye is not licensed to be used in this procedure, and was not developed for this purpose. It is however commonly used and very effective. The use of unlicensed substances is very common and something for which we should all be grateful. The hospital is obliged to tell patients of this and also to advise them of the risks involved in this procedure, for insurance reasons amongst others. Many people feel slightly nauseous for a few seconds after the injection, others may experience some slight allergic reaction on their skin afterwards, and very rarely, – one in about 25,000 patients will experience a more severe reaction which will be dealt with immediately by the emergency team. The benefits of the procedure are considered to far outweigh any risk.

I have had 3 angiograms and am still here to tell the tale! Before the procedure begins you will have your blood pressure checked and pupils dilated. You will be asked about allergies. There is a particular concern about iodine allergy so a bad reaction to shellfish would be something which must be disclosed. After your pupils have been dilated a cannula will be placed in a vein in your arm. You will be seated in front of a camera with chin and forehead rest and a series of rapid photographs will be taken. The dye is then injected via the cannula and this is the point at which nausea may be felt. I have only experienced this feeling once. On the other two occasions the officiating nurse believed that injecting the dye very slowly prevents nausea and this seemed to work.

More photos are then taken accompanied by more flashing lights, and after a while you will be allowed to rest for a few minutes. Then the final photos are taken. It is normal for the cannula, – now disconnected from the dye to be left in the arm until you are discharged, after about 30 minutes to allow you to recover and to check that no side effects occur. Some patients may need antihistamines for rash or redness at the cannula site. Tea and coffee is supplied in my clinic.

For 24 – 48 hours afterwards your skin and urine may appear orange or yellow, this is harmless and nothing to worry about. Drinking a lot of water should help to get rid of the dye. Then you are free to go. The doctor will generally discuss the results with you on your next visit. The only problem I have experienced apart from momentary nausea is with the insertion of the cannula. This very much depends upon the nurse. I have been very fortunate in having the same excellent nurse do this twice and it was totally painless. It is after all a very small cannula and a very fine needle used in this procedure. On one occasion a male nurse had seven tries in one arm and four in the other and was unable to insert the needle. It was excruciatingly painful. Having had a much larger cannula inserted by a paramedic on one occasion and a doctor on another I knew that the individual must be inept. Eventually I suggested that they try the wrist and this was successful. He had been suggesting a direct injection of the dye without the cannula but I was reluctant because I had no confidence in him by this time. I was later told that it is never a good idea to allow multiple attempts at inserting a cannula, or at drawing blood, as permanent and serious damage could be done.

I can‘t help but feel that it is the HCPs who ought to be aware of this and that the onus should not lie with the patient. In fact staff should be properly trained and proficient before being allowed to practice upon patients. I have heard from others that my experience is, by no means unusual or uncommon. If the cannula is not inserted properly and the dye escapes into the surrounding area it can cause burning which, while not serious, should be avoided if possible.

I have a great deal of sympathy for anyone asked to have an FFA shortly after diagnosis, I can well imagine the anxiety this would cause. I have had 3 FFAs in 3 years but this is unusual. It depends on the individual eye condition.

As with many tests and procedures the anticipation is worse than the experience. A newly diagnosed person may feel that this is only the beginning of a series of invasive tests but this is not the case at all. If you are a new patient and FFA is recommended it will certainly help in diagnosis and to pinpoint areas where treatment may be necessary. Most hospitals produce their own fact-sheets about these procedures, but these vary a great deal, and can  be misleading. I would advise anyone who is at all concerned to look at the information provided by several different hospitals which are usually available online in PDFs. This provides a fuller picture. Your hospital will always answer questions, but it is worthwhile doing your own research as it is very easy to misunderstand and not all hospital staff can be familiar with every procedure. Confusing and sometimes slightly uncomfortable as these tests may be it is worth while reflecting that not so long ago none of them were available and diagnosis and treatment would not have been possible until it was too late. It is much rarer for people to lose their sight completely these days and many new treatments are in the pipeline.

Next time I would like to share my experience of laser and eye injections .in the hope that they will be of interest and use to others. These are matters which worry many diagnosed with retinopathy

Kath

Posted in Diabetic complications, Living with diabetes, Support for diabetics | Tagged , , , , , , , | 1 Comment

Statins is the big con over? Catalyst: patients stop taking cholesterol drugs, says survey !

Huge numbers of people on potentially life-saving cholesterol medication have stopped taking it without consulting their doctor after watching an ABC television program, a survey of GPs has indicated. Up to 40 per cent of patients who were concerned by the Catalyst episodes had already gone off their medication, the survey found.
The two-part Catalyst series, presented by Dr Maryanne Demasi, claimed the causal link between saturated fat, cholesterol and heart disease was “the biggest myth in medical history” and cholesterol medications, known as statins, were toxic and potentially deadly. The second episode carried a warning that it should “not be taken as medical advice”.
Heart Foundation national director of cardiovascular health Rob Grenfell said the results were “frightening”.
The survey was commissioned by Merck Sharp & Dohme – which created the first statin in the early 1980s – and undertaken by market research company Cegedim, which surveyed 150 doctors.
It found 40 per cent of patients asking about statins had already stopped taking them, and the remaining 60 per cent wanted to stop.
About 58 per cent of those patients were considered to be at high risk of heart attack or stroke.
“These are people who should be on medications,” Dr Grenfell said. “If your risk is greater than 20 per cent – that is, you have a one in five chance of having a heart attack or stroke in the next five years – you should be treated.”
People with elevated cholesterol levels but a lower risk of heart attack because they do not have other risk factors such as diabetes or high blood pressure, should still take steps to improve their health. But Dr Grenfell said it was difficult for GPs to help people implement lifestyle changes, as many factors were out of their control.
More on this story here.
Eddie
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New blood glucose monitors sync to smartphones, send data to the cloud

This may be of interest to any gadget/tech loving diabetics who are reading…

A snippet…

“The latest offering in that space is Dario, a cloud-based mobile health platform that serves as an all-in-one glucose monitoring system. New York-based LabStyle Innovations plans to launch an iOS mobile app for the Dario on December 12 in the UK, Australia, and New Zealand, reports TechCrunch. A palm-size glucose monitor, with a lancet, strips, and a meter, is also part of the package, and will be commercially available in Europe after a soft launch in early 2014.”

More here

Paul

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Mark Sisson: It’s a way of eating and a lifestyle

A short video but worth a watch. Paul

Posted in Low carb diet, Primal diet | Tagged , , , , , | 1 Comment