Blast It! Starting on Multiple Meds Makes Sense

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Skimming through the latest edition of the diaTribe newsletter, my interest perked up when I read a report on the Banting Lecture by Dr. Ralph DeFronzo of the University of Texas Health Science Center and recipient of the 2008 Banting Medal for Scientific Achievement. In particular, his criticism of the American Diabetes Association’s treatment guidelines, “which recommend lifestyle changes and metformin as initial therapy for Type 2 diabetes,” jumped out at me.

He recommends instead beginning with a triad of drugs: metformin (brand name Glucophage and others), exenatide (Byetta), and a thiazolidinedione, or TZD, such as pioglitazone (Actos) or rosiglitazone (Avandia).

“Dr. DeFronzo’s rationale for multiple drug therapy,” the article says, “was to simultaneously treat the multiple organ dysfunctions that contribute to diabetes and at the same time protect surviving beta cells, and possibly augment them.”

It’s a method that endocrinologist Allen B. King, cofounder and director of the Diabetes Care Center in Salinas, California, has used for years. He calls it “Blast and Taper Fast.” I’ve been to his clinic a couple of times to get my basal doses tweaked. It’s an awesome place.

At the time I talked to Dr. King about Blast and Taper Fast, Byetta, which basically helps your body produce the right amount of insulin at the right time, was not yet on the market. Depending on an individual’s fasting blood glucose levels, Dr. King “blasted” him with up to three drugs: a TZD, which improves the body’s insulin sensitivity; metformin, which adds insulin-sensitizing and glucose-lowering properties to the mix, and a sulfonylurea to stimulate the pancreas to release more insulin.

As you can see, Dr. DeFronzo has substituted Byetta for Dr. King’s sulfonylurea.

I wish I could have talked to Dr. King to get some follow-up information, but the Fourth of July holiday weekend and my impending departure for Camp Lobegon put the kibosh on that.

Still, the idea itself of “blasting” high blood glucose levels with a combination of drugs is, in my opinion, very superior to the “step-up” method: starting with one drug, raising the dose, adding something else, raising the dose of that one, and on and on.

It’s psychological.

“I’m a failure!” the latter method screams. “I can’t take care of my diabetes! The doctor gave my medicine, and I STILL can’t get my BGs down!”

Of course, many doctors fail to explain that, by the time you’re diagnosed with Type 2 diabetes, up to 80 percent of your beta cells may already be kaput. They also fail to explain that more beta cells will fail over time and you’ll need more medicines, or even insulin, to help you manage your diabetes.

There you are: Your blood glucose is high, you’ve just been diagnosed with Type 2 diabetes, and you get one drug that brings your levels down…just a little bit.

So your doctor ups the dose. Meanwhile, in many cases, admonishing you for being “noncompliant.” “You’re not following your diet,” Doc says. “You’re not exercising. If you don’t get that weight off and get your sugar down, I’m going to have to put you on insulin.”

In reality, you aren’t getting the right kind of—or enough—medicine.

How much better is it to start you out with a variety of drugs that target different areas and to reduce the doses or take them away as your blood glucose levels decrease?

“Yay! I’m doing great! The doctor is reducing my doses! I don’t have to take X drug any more!” the “Taper Fast” part says.

Besides, Dr. King says, it takes more medicine (or insulin) to bring down a high blood glucose level than it does to maintain optimal glucose levels. In addition, people are more likely to check their blood glucose in the beginning. Seeing improvement in blood glucose levels beats getting constantly high numbers any time. It might even compel you to continue to check your glucose.

Also, with a doctor who “gets it” and who has explained the pathology of Type 2 diabetes, you might even be willing to say, “My numbers have been going up; I think it’s time for a change in medicines.”

That change may include dropping some medicines and adding insulin. It’s not a bad thing: It just means that you need to supplement a hormone that your body doesn’t make enough of. In addition to taking insulin, I also take metformin to help nullify some of my insulin resistance.

Type 2 diabetes is a multifaceted condition. It takes more than one method to help you manage it. Personally, I like Drs. DeFronzo and King’s multidrug technique much better than the ADA’s. Physically and psychologically, it makes much better sense.

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