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二甲双胍 与糖尿病及健康的新视角
Dr. kumar kotegaonkar| Family Medicine
Metformin is safe, effective,better tolerated and Time tested. Exercise regularly and discipline in your diet keeps HBA1C under good controll. Intestinal disturbances settle. Renal function monitoring and watch the
Lipid profile. Have a Ace inhibitor to take care of renal and hypertensive tendency.
Finally do not worry what will be will be as Shakespeare described ageing "Sans eyes, teeth,ears and everything"
Enjoy what life you have without worrying Massacre events.
We've Come So Far, and Yet...
Diabetes was transformed from a malignant disease to a chronic disorder just over 90 years ago when insulin became available. Antrectomy with vagotomy for ulcer—which I scrubbed in on as a surgical rotation student—has gone the way of the history book due to H2 blockers and proton pump inhibitors. These and other medicines have literally transformed the management of the diseases for which they are used.
Richard M. Plotzker, MD
A typical patient with diabetes who has been referred to a specialist can expect to be prescribed two to three glucose-lowering agents, a couple of drugs to control blood pressure, a statin, likely an aspirin, test strips and lancets, and, if unfortunate, some gabapentin or amitriptyline to alleviate a neuropathy. My own computer, and no doubt others, does such a poor job of tracking all of these items and the frequent changes to them that we ask patients to stuff all of their bottles into a plastic grocery bag and bring them to each visit. Some of these bags weigh more than a pound.
Of course, we need some means of keeping score on how things are going, so we have created any number of measures, such as the hemoglobin A1c, lipid panel, blood pressure reading, and the urine microalbumin screening. It makes for a busy 15-minute office visit that in reality is rarely just 15 minutes. And, unfortunately, all of this still does not tell us what we really want to know, namely: Did we pick the best treatment program from among our realistic options, the one that extends life?
In fact, although our menu of treatment options has expanded considerably, we have surprisingly little consensus on what to prescribe other than metformin for most patients with type 2 diabetes and insulin for all patients with type 1 diabetes. Moreover, we continue to have a fair amount of divided opinion as to how to cope with some of the misadventures inherent in even the most common prescribing.
This We Know: Metformin Associated With Lower Mortality
Two recent studies attempted to address these dilemmas. The first looked at survival among a very large cohort in Belgium, some 100,000-plus patients with type 2 diabetes who had been prescribed metformin, a sulfonylurea, or insulin either alone or in combination from 2003 to 2007.[1]
Unlike in the United States, where care and payment for it is highly fragmented among locations and insurers, in Belgium a single payment source covers much of the population, so the researchers had a large database from which to determine who took which medicines, when they were introduced, and how people did on them, using mortality as the endpoint. Moreover, they could match 12 controls for each patient, matching hypertension for hypertension, heart disease for heart disease, age for age, and then follow survival.
They found what others had anticipated. Patients on metformin monotherapy had longevity similar to that of controls, while those on insulin and/or sulfonylureas did not do as well; all groups, those with diabetes and the control patients, seemed to do better if statins were used as part of the management. The researchers also found that younger people with diabetes were pretty invincible compared with controls irrespective of their treatment plans.
Yet, despite the elegance and thoroughness of the analysis, it still doesn't tell us what we want to know: Do people on metformin do better because metformin is a superior drug, or were they destined to do better because their hyperglycemia is easier to control than those who require insulin?
Either way, based on these results, if you have to add a sulfonylurea or insulin, even if thoroughly appropriate, that change comes with a likely reduction in longevity.
Still Room for Discomfort and Uncertainty
The other study involves a much more limited and focused review, yet one very important to understanding how prescribers deal with the reality that even the most useful of medicines creates its share of dilemmas or even misadventures.[2]
Questionnaires were sent to prescribers asking them how they would manage some of the common branch points that metformin often imposes: partial efficacy, safety limitations such as borderline renal function or alcoholism, and annoying but not threatening gastrointestinal effects. While the study was small, there was a good deal of divided opinion on when the appropriate response would be to increase the metformin dose, add another agent, or discontinue the metformin entirely, all from prescribers with 5-15 years of prescribing experience.
Reconciling what the two studies seem to demonstrate, on one hand, we should go out of our way to maintain metformin as the core of our patients' diabetes regimens as much as possible. On the other hand, it appears that we know less than we would like to know about even the most beneficial and commonly prescribed drug in type 2 diabetes.
So far, I have always approached the need for more meticulous glucose management with insulin or sulfonylureas in a cheerful way, promising patients that if they take my sage advice, they will feel better at the next visit because of it. I have never told anyone that having to do this now might be an ominous prognostic sign for down the road, but now I wonder whether my underlying optimism inadvertently makes me a little less candid that perhaps I should be.
Metformin is safe, effective,better tolerated and Time tested. Exercise regularly and discipline in your diet keeps HBA1C under good controll. Intestinal disturbances settle. Renal function monitoring and watch the
Lipid profile. Have a Ace inhibitor to take care of renal and hypertensive tendency.
Finally do not worry what will be will be as Shakespeare described ageing "Sans eyes, teeth,ears and everything"
Enjoy what life you have without worrying Massacre events.
We've Come So Far, and Yet...
Diabetes was transformed from a malignant disease to a chronic disorder just over 90 years ago when insulin became available. Antrectomy with vagotomy for ulcer—which I scrubbed in on as a surgical rotation student—has gone the way of the history book due to H2 blockers and proton pump inhibitors. These and other medicines have literally transformed the management of the diseases for which they are used.
Richard M. Plotzker, MD
A typical patient with diabetes who has been referred to a specialist can expect to be prescribed two to three glucose-lowering agents, a couple of drugs to control blood pressure, a statin, likely an aspirin, test strips and lancets, and, if unfortunate, some gabapentin or amitriptyline to alleviate a neuropathy. My own computer, and no doubt others, does such a poor job of tracking all of these items and the frequent changes to them that we ask patients to stuff all of their bottles into a plastic grocery bag and bring them to each visit. Some of these bags weigh more than a pound.
Of course, we need some means of keeping score on how things are going, so we have created any number of measures, such as the hemoglobin A1c, lipid panel, blood pressure reading, and the urine microalbumin screening. It makes for a busy 15-minute office visit that in reality is rarely just 15 minutes. And, unfortunately, all of this still does not tell us what we really want to know, namely: Did we pick the best treatment program from among our realistic options, the one that extends life?
In fact, although our menu of treatment options has expanded considerably, we have surprisingly little consensus on what to prescribe other than metformin for most patients with type 2 diabetes and insulin for all patients with type 1 diabetes. Moreover, we continue to have a fair amount of divided opinion as to how to cope with some of the misadventures inherent in even the most common prescribing.
This We Know: Metformin Associated With Lower Mortality
Two recent studies attempted to address these dilemmas. The first looked at survival among a very large cohort in Belgium, some 100,000-plus patients with type 2 diabetes who had been prescribed metformin, a sulfonylurea, or insulin either alone or in combination from 2003 to 2007.[1]
Unlike in the United States, where care and payment for it is highly fragmented among locations and insurers, in Belgium a single payment source covers much of the population, so the researchers had a large database from which to determine who took which medicines, when they were introduced, and how people did on them, using mortality as the endpoint. Moreover, they could match 12 controls for each patient, matching hypertension for hypertension, heart disease for heart disease, age for age, and then follow survival.
They found what others had anticipated. Patients on metformin monotherapy had longevity similar to that of controls, while those on insulin and/or sulfonylureas did not do as well; all groups, those with diabetes and the control patients, seemed to do better if statins were used as part of the management. The researchers also found that younger people with diabetes were pretty invincible compared with controls irrespective of their treatment plans.
Yet, despite the elegance and thoroughness of the analysis, it still doesn't tell us what we want to know: Do people on metformin do better because metformin is a superior drug, or were they destined to do better because their hyperglycemia is easier to control than those who require insulin?
Either way, based on these results, if you have to add a sulfonylurea or insulin, even if thoroughly appropriate, that change comes with a likely reduction in longevity.
Still Room for Discomfort and Uncertainty
The other study involves a much more limited and focused review, yet one very important to understanding how prescribers deal with the reality that even the most useful of medicines creates its share of dilemmas or even misadventures.[2]
Questionnaires were sent to prescribers asking them how they would manage some of the common branch points that metformin often imposes: partial efficacy, safety limitations such as borderline renal function or alcoholism, and annoying but not threatening gastrointestinal effects. While the study was small, there was a good deal of divided opinion on when the appropriate response would be to increase the metformin dose, add another agent, or discontinue the metformin entirely, all from prescribers with 5-15 years of prescribing experience.
Reconciling what the two studies seem to demonstrate, on one hand, we should go out of our way to maintain metformin as the core of our patients' diabetes regimens as much as possible. On the other hand, it appears that we know less than we would like to know about even the most beneficial and commonly prescribed drug in type 2 diabetes.
So far, I have always approached the need for more meticulous glucose management with insulin or sulfonylureas in a cheerful way, promising patients that if they take my sage advice, they will feel better at the next visit because of it. I have never told anyone that having to do this now might be an ominous prognostic sign for down the road, but now I wonder whether my underlying optimism inadvertently makes me a little less candid that perhaps I should be.