From Los Angeles, California, USA:
I was diagnosed with type 2 diabetes three years ago. I am 35, male, Caucasian, 155 pounds. My blood pressure and cholesterol are normal.
At the time of diagnosis, my A1c was 11.2 and my fasting blood sugars were over 270 mg/dl [15.0 mmol/L]. Upon implementing a strict diet and exercise routine, my A1c fell to below 5.9 and has remained below 5.9 every three months for three years. Recently it was 5.4. But, my fasting blood sugar, during the past three years, has hovered consistently between 120 mg/dl [6.7 mmol/L] and 155 mg/dl [8.6 mmol/L]. Should I take metformin to reduce my fasting blood sugar number, or is it fine to continue my diet and exercise plan, as long as my A1c tests continue to show results below 5.9?
The American Diabetes Association now recommends that all patients diagnosed with type 2 diabetes should take metformin along with lifestyle changes (meal planning and physical activity). Metformin will lower your fasting blood sugar by stopping the liver from sending stored glucose in the liver back into the bloodstream. Talk to your doctor about this. Your kidney function has to be checked before you start metformin.
Additional comments from Dr. Stuart Brink:I do not think that metformin is "mandatory." However, fasting hyperglycemia with a normal A1c is not normal and it would be reasonable and prudent to try to "fix" this fasting hyperglycemia with metformin. Glitazones would also be reasonable. The bottom line is getting closer to normal and the A1c only looks at averages for the previous four to six weeks. Day-by-day blood glucose testing, as in this example, should warrant food, activity, weight and/or medication changes to meet goals of normality as well as long as there are no concomitant side effects. We would have such a conversation with the patient/family and then decide together how to proceed, whether or not the financial costs, side effects risks/actual side effects, etc. are worth trying to normalize fasting hyperglycemia as well as post-prandial hyperglycemia by using blood glucose profiles, in addition to A1c levels. Unfortunately, there is not as much science/evidence based science to help in this regard but common sense and philosophy of treatment and open discussion is important.
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