Wednesday, December 29, 2010

How To Wean Off of Diabetes Medication Michael Dansinger, MD

One of my greatest pleasures in life is to help patients achieve remission of their type 2
diabetes. This means their blood sugar levels have become normal in the absence of
any diabetes medication.

Many clinicians and patients are interested in learning my views about how to go about
decreasing and discontinuing diabetes medications. The main role for medications is to
help reduce or delay the risk of nasty complications of diabetes, particularly the damage
to the retina, kidney, nerves, and circulation. The higher the average blood sugar level,
as indicated by the hemoglobin A1c level, the greater the complication risk (which
increases exponentially with increasing A1c). We know from clinical trials that using
medication to keep the A1c at or below 7% can help reduce the risk of these
complications. There is broad agreement that clinicians should recommend starting or
increasing diabetes medications to patients who cannot get their A1c level to 7% or less
via lifestyle change.
Many patients come to me because the A1c is already over 7% and their primary care
provider proposes increasing their diabetes medication, unless the patient can get to 7%
or less with improved eating and/or exercise habits. Some of these patients are already
on many pills, and insulin shots are the frequently the next appropriate treatment. Many
patients would rather make the lifestyle changes than take more medication, so when
the doctor frames the issue in this way, then a patient might become inspired to renew or
increase the lifestyle efforts. The clinician might say lets recheck the A1c in 3 months,
and start the new medication if it is still above 7.0%.

My goal with patients is to use the lifestyle strategies Ive discussed previously in this
blog to drive the A1c as low as possible. I want to push the A1c very far below 7.0%. If
possible I would prefer to push the A1c into the normal range of 5.7% or less, and Ive
helped many patients push it close to 5.0%. There can be little doubt that using lifestyle
changes to normalize the glucose levels and A1c is a good thing. In contrast, the
strategy of driving the A1c well below 7.0% with multiple medications has little to offer
most patients in terms of quality of life or reduced risk of complications.

Most patients I see are already taking metformin, which is the preferred second line
treatment after lifestyle change. Opinions differ about when to start this drug. Some
experts advocate starting it in patients who have pre-diabetes because clinical trial
evidence demonstrates that it can delay the progression to type 2 diabetes, while other
experts could argue that there is little evidence that it reduces diabetes complications
when the A1c is below 7.0%, so no point in starting it until 7.0% It is important to discuss
these issues with patients.

I typically recommend initiating it in patients with A1cs of 6.5% who cannot push it any
lower via lifestyle change. For patients who are already on metformin, I do not decrease
the dose unless the A1c is 6.0% or less. I might reduce the dose by half every 3 months,
as long as the A1c stays at 6.0% or less. I stop the final 500 mg of metformin when the
A1c is 6.0% or less for at least 3 months. Once a patient has discontinued it, I would
then recommend restarting it if the A1c reaches 6.5%. Other alternative approaches
would also be reasonable, and patient and physician preferences should be taken into
account when making such decisions about starting and stopping metformin.

Some drugs can lower the blood sugar levels below the normal range, causing
symptoms of hypoglycemia. These drugs, which include insulin and those in
thesulfonylurea family (which are common in patients on more than one kind of diabetes
pill) need to be reduced or discontinued by the clinician as required to avoid
hypoglycemia, so these are typically the first drugs to be discontinued. It is important
that patients who take these medications check their blood sugar levels regularly,
particularly while making lifestyle changes. Doing so lets us know the risk of future
hypoglycemia and guides the decision about when to decrease or discontinue such
medications.

For patients on insulin, this type of monitoring is mandatory. Initially, insulin dose
reduction typically mirrors dietary carbohydrate reduction, and many patients are quickly
using half as much insulin, particularly the short-acting insulin boluses used to prevent
hyperglycemia during and after meals. Weight loss often brings additional reductions
and sometimes discontinuations of insulin, however the glucose and A1c levels are the
key to managing insulin dosing over time. The majority of my patients have not been
able to discontinue insulin altogether, although nearly all of them have been able to
significantly reduce their dose as well as their A1c levels. The chances of discontinuing
insulin are best when the lifestyle adherence levels are high, the weight loss is large, the
initial insulin requirement is relatively low, and the duration of diabetes is short, almost
always less than 10 years.
In the absence of insulin or sulfonylureas, then other drugs (such as pioglitizone) come
off next. I typically wait until the A1c is 6.5% or less to propose stopping such drugs, and
would not initiate or re-initiate any diabetes drugs (other than metformin as noted above)
unless the A1c is above 7.0%.

So, in summary, ambitious eating and exercise goals are important in all stages of
diabetes, and drugs are crucially important in patients who cannot otherwise keep the
A1c below 7.0%. Metformin is the first drug of choice whenever possible, and the last
drug to be discontinued in patient who normalize glucose levels via lifestyle changes.
The A1c levels to start and stop metformin are up for debate, and may be individualized
according to patient and clinician preferences. It is clear that medications can be
avoided, delayed, or discontinued when lifestyle efforts are intensified and sustained.
For many (if not most) patients, lifestyle coaching by a clinician, dietitian, personal
trainer, peer group, etc. can dramatically increase the odds of success.
- Michael Dansinger, MD

Posted by: Michael Dansinger, MD at 9:48 am

 , 29 , 2010

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