While most practitioners tend to start out slow and build up dosages when prescribing oral medications for people with type 2 diabetes, Allen B. King, MD, FACE, CDE, prefers to use what he calls the “Blast and Taper Fast” method.
Using fasting blood glucose levels as a starting point, Dr. King, who is the cofounder and medical director of the Diabetes Care Center in Salinas, California, may “blast” patients with up to three different oral medications. As blood glucose levels drop, the number of medications and/or the dosage levels are tapered off-fast.
The reasoning behind “Blast and Taper Fast”? Because it takes more medication to bring a high blood glucose reading down than it does to maintain a normal level, the center’s preference is to “blast” the high with enough firepower to lower blood glucose to normal levels. Also, people are more willing at the start of their treatment to test their glucose and take medications, Dr. King says. It helps, psychologically, to see an improvement in their diabetes.
Different Kinds of Meds
While most doctors favor beginning with Glucophage (metformin), Dr. King prefers to start with one of the insulin sensitizers known as thiazolidinediones (TZDs, or glitazones). Specifically, he suggests using Actos (pioglitazone).
Although Glucophage does reduce blood glucose without hypoglycemia or weight gain, “probably one third of the people experience nausea, vomiting and diarrhea,” he says. In addition, there is a small, but real, danger of developing lactic acidosis, which can be fatal.
TZDs also lower blood glucose without causing hypoglycemia, plus they have additional benefits, according to Dr. King, including improved lipid profiles and reduced microalbumin.
Dr. King does, however, acknowledge that TZDs have their faults: they are associated with weight gain-from fluid retention and from increased fat deposits. But, he notes, they also change fat deposits from the “bad” abdominal fat that is associated with diabetes and heart disease to the more benign subcutaneous fat.
Strategy and Tactics
If fasting blood glucose is between 126 mg/dl and 150 mg/dl after a patient has completed a two- to six-week trial period of increased activity and eating changes, the patient begins a regimen of oral medication (in addition to continuing those lifestyle changes). Dr. King starts these patients on 30 mg of Actos.
For individuals with higher fasting blood glucose levels, he adds Glucophage, and then a sulfonylurea (preferably Amaryl) in correspondingly higher doses (see the table on page 22). Each drug targets a different site: Actos is an insulin sensitizer; Glucophage adds to the glucoselowering properties of Actos, still without causing hypoglycemia; and the sulfonylureas stimulate the pancreas to produce more insulin.
Dr. King chooses these drugs for convenience as well as for their anti-hyperglycemic properties. For example, Amaryl may be associated with less hypoglycemia and less cardiac toxicity than other sulfonylureas, and generally can be taken once a day, he states.
As blood glucose levels come down, dosages are decreased and some medications are eliminated. The goal is to gain optimal control using the fewest medications and the lowest dosages.
If patients fail to respond to the “blast” within two weeks, Dr. King initiates insulin therapy. By the time most people are diagnosed with type 2 diabetes, he explains, about half of their insulin production is gone. “Within 10 to 12 years,” he says, “most type 2s end up on insulin.”
Whether it’s taking multiple medications or beginning insulin therapy, the key to avoiding diabetes-related complications is doing whatever it takes to achieve optimal glucose control and being flexible as an individual’s needs change over time.