I am 49 years old, weigh 100 kg (222 pounds) and am 5 feet, 7 inches. My A1c has always been under 6.5, but after five years of metformin, I feel it is no longer working well because I sometimes have post-prandial spikes over 200 mg/dl [11.1 mmol/L]. What other medication could I take? Could I achieve better control by stopping the metformin and adhering to a very strict diet?
As long as the HbA1c is accurate for you, a value below 6.5% is very good. This suggests the metformin is truly working. I say working for you because some people may have blood diseases, such as the hemoglobinopathies, where the HbA1c is not accurate. You would know this if it were the case. You would know it most of the time because the laboratory test would tell you if there were a problem. I would not stop the metformin. The American Diabetes Association has indicated that a target for HbA1c is <7.0%. Although 6.0% is usually the upper limit of normal for most laboratories, a value of 6.5%, maintained chronically, clearly has benefit in terms of avoiding the long-term complications to the eyes, nerves, and kidneys. We are less sure about the heart and brain for prevention of heart attack and stroke. Most post-prandial glucose values should be <140 mg/dl [7.8 mmol/L] if they were normal. One approach would be to examine what you are eating and see if it is too much at any one meal. You may need the help of a dietitian or a professional with expertise in nutrition. If you are eating appropriate amounts of food at meals and still getting high post-meal blood sugars, you may want to consider a mild hypoglycemic agent, such as Prandin, to be added at meals. This works for a short time around a meal and is gone after several hours, but is only to be given before the next meal. As always, avoidance of obesity and regular physical activity are important.
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