Metformin not working anymore

When Type 2 Diabetes Treatment Fails, What’s Next?

Diabetes is a progressive disease and when your treatment plan is no longer controlling your blood sugar, it’s time to create a new one. Clementa Moreno/Getty Images

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For most people, type 2 diabetes changes over time — even for those who follow their treatment plan exactly as directed. Diabetes is a progressive disease, meaning your diet, exercise, and medication needs will likely change with time. That doesn’t mean you did something wrong; shifting gears is a natural part of managing a changing chronic disease like type 2 diabetes.

Your diabetes care team can help you adjust your treatment plan and manage your blood sugar levels. If a change is needed, your doctor may adjust your current medication, add new diabetes medications, or suggest starting an insulin regimen.

Why Your Diabetes Treatment Plan May Change

There are a number of factors that can contribute to a decline in blood sugar control, says Margaret Powers, PhD, RD, CDE, who has served as president of healthcare and education for the American Diabetes Association and is a registered dietitian, certified diabetes instructor, and research scientist at the Park Nicollet Health Clinic in Minneapolis.

When type 2 diabetes first develops, you may be insulin resistant, which means you make a lot of insulin, but your body can’t use it effectively, Dr. Powers says. Then, over time, you make less insulin and become insulin deficient. “This is seen a lot, but it doesn’t happen overnight; it’s a gradual process,” says Powers. Other factors can also affect blood sugar, including a significant change in weight, activity level, or diet or starting a new medication, she says.

Stress can also impact your treatment. When you’re chronically stressed, your body produces hormones that might cause your blood sugar to rise. An additional illness or a major change like a divorce, job loss, or loved one’s death can cause prolonged stress, which can raise blood sugar.

Stressful life changes may also affect how well people take their medication, adds Susan Weiner, RDN, a certified diabetes educator in New York and the American Association of Diabetes Educators’ 2015 Educator of the Year. “Before, there may have been someone who helped motivate and support the person with diabetes. And daily diabetes self-management can be challenging even under the best of circumstances,” she says.

If you need to change things up, it doesn’t necessarily mean you’ll need to adjust your medication regimen. It may just be a matter of refocusing on your food and activity plan, as well as reducing stress.

Consider taking these steps to get your type 2 diabetes treatment back on track.

Monitor your blood sugar and A1C levels to gauge treatment success

An A1C test measures your average blood glucose (sugar) levels over the past three months. It’s the test that’s used to diagnose prediabetes and diabetes and also to help track and manage the condition. Your results are reported with a percentage.

Generally speaking, a reading of less than 7 percent is usually optimal to prevent type 2 diabetes complications. Your target may be higher or lower, so be sure to talk to your diabetes care team about your personal A1C goal.

While A1C tests are a good indicator of how well treatment is working overall, Powers explains that the A1C reflects an average. That means you could actually be experiencing many highs and lows, depending on what you eat and whether you exercise, even if your A1C result seems normal.

That’s why at-home blood sugar testing as prescribed by your doctor is also important. Regular monitoring shows your blood sugar levels on a day-to-day basis. If your numbers aren’t consistently within your target range, you may need a change in treatment.

Most people with diabetes should see their doctors about every three to four months to get their A1C, blood pressure, blood sugar, and cholesterol levels checked and to reevaluate their treatment plan as necessary. You may need to see your doctor more or less frequently, depending on your treatment plan and blood sugar control. According to Powers, there are four critical times to have your diabetes self-management plan assessed:

  • When you are newly diagnosed
  • Annually
  • When complicating factors occur
  • When you have transitions in care

There are many factors that can affect your A1C, so it’s important to review your diabetes management plan regularly so you don’t miss the opportunity to do what’s best for you.

Keep up with healthy lifestyle changes

Anyone who’s started a new diet or exercise program knows sticking to it for the long haul is often the most challenging part. But it’s essential to maintain lifestyle changes to get the best diabetes control, says Powers. Even diabetes medications, she says, won’t work on their own.

Important lifestyle changes to manage your diabetes include:

  • Eating a healthy diet to keep your blood sugar levels stable, with the help of your diabetes educator or a registered dietitian. While there is no one-size-fits-all diet, for most people it means cutting back on calories and saturated fats; reducing carbohydrates and distributing them evenly throughout the day; and bumping up your intake of vegetables, fruits, and other high-fiber foods.
  • Getting more physical activity, which helps lower blood sugar. Aim for 30 to 60 minutes most days of the week — everything from walking and gardening to swimming and biking — and combine that with two days of resistance training, such as weight lifting or yoga, for the best results.
  • Losing weight, which also helps lower blood sugar levels. Even 5 to 10 pounds can make a difference.

Work with your doctor to adjust treatment as needed

While some people with diabetes can manage their blood sugar with lifestyle changes, including losing weight, eating a healthy diet, and exercising regularly, many others require diabetes medications. Metformin is a typical first medication for people with type 2 diabetes, says Powers. It works by decreasing the amount of sugar the liver produces and making muscle cells more sensitive to insulin so sugar can be absorbed.

If metformin no longer works for you, your doctor may add another drug to your treatment plan. “But there’s no magical second drug; the secondary options will depend on the individual,” she says.

Your doctor may prescribe other oral medications or noninsulin injectables. There are several different classes of diabetes medications that work to lower blood sugar in different ways. For instance, some trigger the pancreas to release more insulin, while others work in the intestines to block the breakdown of some carbohydrates or in the kidneys to increase the amount of sugar excreted in urine. Your doctor may suggest adding one or more of these to your medication plan. You’ll know your new medication is working if your A1C numbers shift down toward your goal.

If you’ve had type 2 diabetes for many years, there may come a time when the medications you’ve been taking and lifestyle changes you’ve made might not work anymore. As a result, insulin injections may be needed in people whose A1C numbers are very high, Powers says. Keep in mind that although insulin therapy used to be added only when other medications weren’t working, it’s sometimes started earlier these days for people with type 2 diabetes.

“Work with your healthcare provider, who will be able to recommend the best way to adjust your medications and insulin dosage so you can continue to properly manage your type 2 diabetes,” she says.

Stay positive when your type 2 diabetes changes

“Don’t feel like you’re in this alone,” Weiner says. Reach out to a friend, family member, healthcare provider, or certified diabetes educator for support.

Additionally, take measures to manage stress. “Recharge and do something you enjoy: Take a walk, cuddle a pet, listen to music, or treat yourself to a massage,” she says.

Additional reporting by Colleen de Bellefonds

A huge assortment of 100 medications are available to treat high blood sugar in Type 2 diabetes, including two historical breakthrough drugs, insulin and metformin. The pharmaceutical industry has successfully added a few new, innovative drugs, but the most effective drugs remain the older, less expensive medications.

Let’s make some sense out of this mess of medications.

Most are given by mouth (oral), but injected insulin, which I’ll address in a future blog post, remains a key medication. In addition, oral drugs have limited impact, so they are often used in combinations (including tablets containing two drugs). Patients frequently try multiple oral drugs before starting insulin.

With very few exceptions, I start patients on metformin first.

To illustrate a patient’s experience with diabetes drugs, let’s check in on with Mrs. R., a 70-year-old with diabetes:

When she was first diagnosed 19 years ago, she started on metformin at 500 mg twice per day. These large tablets initially caused intestinal discomfort (a common side effect). Over time, the mild abdominal pain went away. This drug worked well for a few years, but Mrs. R gained some additional weight and the metformin was no longer adequate. The drug, glipizide was added. This also worked for many years, but in 2012, she needed a third drug, sitagliptin. Eventually, she would need insulin.

To understand Mrs. R’s experience, or the medications taken by you or a friend or family member, let’s start with the best medication, metformin.

Approved by the U.S. Food & Drug Administration in 1994, metformin is so critical to diabetes treatment that if you don’t tolerate it at first because of abdominal side effects, it’s worth trying again. Many of my patients who did not tolerate this drug at first did better when they started at low doses and then worked to increase the amount they could easily tolerate.

This is my first-line, go-to drug for diabetes, and I’m always surprised when I encounter a patient with Type 2 diabetes who’s not taking it. And, just to be clear, metformin is a generic and I have no financial interests related to its use. Interestingly, the origin of metformin can be traced back to a herbal remedy from French lilac that has been known since the Middle Ages. Here are just a few reasons metformin is so great:

  • It can help with weight loss, while nearly all other diabetes drugs cause weight gain.
  • Metformin reduces high blood sugar, but rarely lowers blood sugar to levels below normal. Most other drugs have the potential to cause life-threatening hypoglycemia (low blood sugar).
  • This drug can be continued even if it becomes necessary to start insulin.
  • It’s inexpensive, costing pharmacies as little as $0.06 per day of treatment.

Metformin works by increasing the body’s response to insulin, effectively reversing the insulin resistance that causes Type 2 diabetes. Insulin resistance occurs when the body’s liver, muscle and fat cells require more and more insulin in the bloodstream to make them do their jobs.

It’s no surprise that it is widely used, with 72 percent of U.S. diabetes patients who take medications on metformin. It could be used even more often. If you have Type 2 diabetes, you need to be on metformin or have a good reason not to take it (like advanced kidney disease). If you’ve tried it and have had indigestion or other abdominal problems, it may be worth trying this wonder drug again.

There are six other major classes of blood-sugar lowering drugs used in Type 2 diabetes. While none of these drugs (except for insulin) are in the wonder drug category, quite often these medications are combined with metformin to get blood sugar back towards normal levels. We will review these next-best drugs in the next blog post.

Randall Stafford, MD, PhD, a professor of medicine and director of the Program on Prevention Outcomes and Practices, practices primary care internal medicine at Stanford. He is developing practical strategies to improve how physicians and consumers approach chronic disease treatment and prevention.

This is the sixth piece in the series, “Breaking Down Diabetes,” created for those with or at risk for diabetes as well as their family and friends. Previous blog posts addressed the pre-diabetes, diabetes complications, and goals for diabetes beyond blood sugar. Some data for this report come from IQVIA, Inc., previously known as QuintilesIMS. For additional information, please contact [email protected]

Image by mcmurryjulie

So you’ve just been diagnosed with prediabetes. It’s probably overwhelming enough to hear that, but on top of it, your doctor wants you to start taking a medication called metformin. The only thing you took away from your appointment was that it might cause diarrhea, nausea, and gas. Should you even take it? It’s not like you have full-blown diabetes. What’s the big deal?

Why do I need metformin?

According to the American Diabetes Association (ADA), prediabetes is when your blood sugar levels are higher than what is considered normal but not yet high enough to be classified as true diabetes (fasting blood sugar between 100 mg/dL and 125 mg/dL and/or an HbA1C (hemoglobin A1C) between 5.7% and 6.4%).

Prediabetes isn’t considered a true medical condition but, instead, a risk factor for type 2 diabetes and cardiovascular disease. Don’t let the “pre-” in prediabetes fool you. It doesn’t mean it’s less of a health concern than diabetes. It’s a warning that you could develop type 2 diabetes if you don’t take charge of your health now.

For many people diagnosed with prediabetes, diet and exercise changes are all that are required to manage or reverse it. In fact, proper diet and exercise can reduce your risk of developing type 2 diabetes by 58%!

However, a doctor may prescribe metformin to those who find lifestyle changes aren’t enough or to those at the highest risk of developing diabetes. The term “high risk” takes many things about your personal and family medical histories into account, but in general, examples of high-risk people include those with a body mass index (BMI) greater than 35 kg/m2 and women previously diagnosed with gestational diabetes (diabetes while pregnant).

What does metformin do?

Metformin is an oral medication that helps to control blood sugar levels. It does this by helping your body to make less glucose (sugar) and to use your naturally produced insulin more effectively. It is available in immediate release (IR) and extended release (ER) versions. The brand-name IR version is known as Glucophage, which is available as generic metformin. Then, the ER versions are sold under the brand names Glumetza, Fortamet, and Glucophage, and each has their own generic versions.

For those at high risk of developing diabetes, metformin can be a great choice. The medication has been studied for several decades and is very safe and easy to use. It has a very low risk of sudden hypoglycemia (an unsafe drop in blood sugar) and requires minimal monitoring by both you and your doctor.

It is also an effective medication, with the most research to support its treatment of prediabetes in those under 60 years old. In fact, it is the only medication the ADA currently recommends for prediabetes.

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What are the common side effects of metformin?

Diarrhea, nausea, vomiting, and gas are the most common side effects of metformin. I know, that sounds like no fun. But the good news is that these gastrointestinal (GI) issues usually disappear within the first 2 weeks of starting the medication. Two things can help prevent or manage these side effects:

  • Take metformin with a meal. Metformin is more likely to bother your stomach when it’s empty. Your best bet is to take it while eating or right after finishing a meal. If you’re only taking it once a day, take it with your biggest meal.
  • Switch to the extended release (ER) version. When you first start metformin, you will most likely be given the immediate release (IR) version. If you continue to have GI side effects after the first 2 weeks of taking it, ask your doctor to write a new prescription for the ER version. The coating on the ER tablets helps reduce the amount of side effects.

Some people and websites will claim that changing your fiber intake or adding probiotics to your diet will also help decrease diarrhea. But these methods haven’t been studied and aren’t currently recommended by the ADA.

Meeting with a dietitian to discuss lifestyle changes for prediabetes is a great idea, and they can make dietary suggestions to help combat GI distress (regardless of whether it’s from metformin or not).

Will I be on metformin forever?

There’s no way to know ahead of time how long you will need to be on metformin. If you fall into the high-risk category, you’re more likely to be taking it sooner and for longer than those at a lower risk of developing diabetes.

Some people will be on metformin for several years because their HbA1C is always in the prediabetes range. This is where talking to your doctor about your expectations and long-term goals is essential; they can tell you how long you can expect to be on the medication.

Chances are, you doctor will have you take metformin for at least a year. This is because it takes about 3 months for your HbA1C to change, and those changes are usually very gradual. If your fasting blood sugar and HbA1C drop to the normal range, your doctor may take you off metformin and see how you do without it. Unlike with type 2 diabetes, metformin only needs to be used for prediabetes while your numbers are high.

Unfortunately for many, achieving a normal HbA1C isn’t easy. You have to work at it every day. Even those who follow all their doctor’s instructions may only have a small reduction in their numbers (or none at all) from blood draw to blood draw. It can get very discouraging, and many people lose motivation. Just try to remember that all your hard work is helping to prevent diabetes, even if you’re not seeing dramatic changes to your HbA1C.

Is metformin right for me?

While metformin isn’t always immediately prescribed when it’s discovered you have prediabetes, it is given to high-risk patients or to those who are having a difficult time managing their HbA1C with diet and exercise. Your doctor will be the one to decide if or when you should take metformin.

It is a safe and effective medication to help prevent type 2 diabetes. While metformin does carry a risk of some unpleasant side effects, they are temporary for most and can be managed with some minor changes to the way you are taking it.

Just remember, prediabetes doesn’t mean you will develop diabetes in the future. It is manageable and, for some, reversible. Let it be the nudge you need to help you take control of your health.

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  • Diabetes Forecast

    Photography by Mike Watson Images/Thinkstock

    There are many type 2 medications, and each drug class works in the body in a different way. Here’s a quick guide to help you understand how long each drug will generally take to work:

    Alpha Glucosidase Inhibitors

    acarbose, miglitol

    These short-acting oral medications, taken with meals, block the breakdown of complex sugars into simple sugars in the gastrointestinal (GI) tract. “Simple sugars are more easily absorbed and cause the blood sugar to ultimately go up,” Sam Ellis, PharmD, BCPS, CDE, associate professor in the Department of Clinical Pharmacy at the University of Colorado says. These drugs are minimally absorbed into the blood, so a certain blood level concentration is not necessary for them to work. You will see the effect immediately with the first dose. “You take it before a meal, and with that meal you see the effect,” says George Grunberger, MD, FACP, FACE, President of the American Association of Clinical Endocrinologists.

    Bile Acid Sequestrants

    cholestyramine, colesevelam, colestipol

    While researchers aren’t exactly sure how these oral medications work, it’s likely that the meds block some absorption of glucose in the GI tract. “You’ll see most of the effect in the first week with these drugs,” says Ellis.

    DPP-4 Inhibitors

    alogliptin, linagliptin, saxagliptin, sitagliptin

    These drugs work to block the enzyme responsible for the breakdown of a specific gut hormone that helps the body produce more insulin when blood glucose is high and reduces the amount of glucose produced by the liver. Take a DPP-4 inhibitor (they come in pill form) and it’ll work pretty fast—you’ll see the full effect in about a week. “It’s blocking that enzyme after the first dose a little bit, but by the time you get out to dose five, you’re blocking the majority of that enzyme,” Ellis says.

    GLP-1 Receptor Agonists

    albiglutide, dulaglutide, exenatide, exenatide extended release, liraglutide

    These drugs are injected, but unlike insulin they mimic a peptide in the body that lowers blood glucose and glucagon levels. (Glucagon is a peptide responsible for raising the concentration of glucose in the blood.) GLP-1 medications also reduce appetite, which can lead to weight loss. There are several formulations on the market, all of which release the medication differently. The rapid-acting, twice-a-day exenatide injection, for example, takes effect immediately. “This is like rapid-acting insulin,” says Grunberger. “When you inject at a meal, you will see the effect immediately.” The once-a-day formulation, liraglutide, is similar to basal insulin and will take 24 hours to affect blood glucose. Three once-weekly formulations also exist, but because of their dissimilar molecular structures, they take effect at different times. People typically experience full blood glucose–lowering effects after two to four weeks of dulaglutide, four to five weeks of albiglutide, and six to seven weeks of exenatide extended release. Keep in mind: If you switch from a twice-a-day or once-a-day formulation to a weekly dose, you may not see the effect of the new drug immediately. “ may potentially lose blood glucose control for a short period of time,” says Ellis.


    nateglinide, repaglinide

    These drugs, taken orally three times daily with meals, stimulate the release of insulin from the pancreas. “They get absorbed very quickly, and they get eliminated very quickly,” says Ellis. Meglitinides will start working with the first dose. Bonus: They don’t have to build up in the system before hitting their maximum blood glucose–lowering effect like some other drugs.


    Metformin works in a few ways. It helps your body properly respond to its insulin, reduces glucose production in the liver, and helps block glucose absorption in your intestines. Metformin is a quick-acting oral medication—you will typically see some effect within 48 hours of starting the medication. Maximum effect will take about four to five days, but that depends on the dose. There’s a good chance you’ll start with a small metformin dose—500 milligrams once a day—and build up over a few weeks until you’re taking at least 1,500 milligrams daily. This slow start method can help you avoid side effects such as upset stomach, but it also changes how quickly you’ll see results. “Patients won’t notice a big change in their blood glucose when they start ,” says Ellis. “We really need to get at least 1,500 milligrams a day before we start to see that drug have much effect on blood sugars.”

    SGLT-2 Inhibitors

    canagliflozin, dapagliflozin, empagliflozin

    SGLT-2 inhibitors, which are taken orally, block a transporter in the kidneys responsible for reabsorbing glucose. This causes glucose to be lost in the urine, which results in lower glucose levels in the body. As with DPP-4s, you’ll see some response from your first dose of an SGLT-2 drug, but it may take a week to see the full response. “Once you get to steady state, you could start to see some of the ,” Ellis says. Those include an increased risk for genital yeast infections.


    chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide

    In large part, these oral medications work very quickly because they stimulate the pancreas’ release of insulin. “You see a response starting with the first dose,” says Evan Sisson, PharmD, MHA, CDE, associate professor in the Department of Pharmacotherapy and Outcomes Science at Virginia Commonwealth University. That said, the maximum effect won’t be seen for a few more days, up to two weeks.


    pioglitazone, rosiglitazone

    For thiazolidinediones to work, they must enter the cells to increase a glucose transporter, a process that takes quite a while. While you may see some effect after two weeks, it could take 18 to 20 weeks before you see the maximal effect. These meds are taken orally.

    Insulin Informed

    Insulin is pretty straightforward in terms of how long it will take to see the effects. Formulations for different absorption rates are available and will be consistent based on which kind you use.

    • Rapid Acting Expect this to begin to work 15 to 20 minutes after injection, peak at about 90 minutes, and last two to four hours.
    • Regular or Short Acting You will start to see the effects after 30 minutes. Regular insulin peaks about two to three hours after injection and is effective for about three to six hours.
    • Intermediate Acting This reaches the bloodstream about two to four hours after injection, peaks at four to 12 hours, and is effective for 12 to 18 hours.
    • Long Acting You’ll see this start to work an hour after injection. There is no peak, and it will keep blood glucose even for 24 hours.
    • Ultra Long Acting While this type will start working after six hours, there is no peak. The effects will last for 36 hours.

    Click here for more about type 2 medications and what it takes for them to work.

    Interested in more information about healthy living with diabetes? Diabetes Forecast magazine.

    Questions and Answers – medication and insulin

    Q: I have type 2 diabetes and have been on insulin for a year now. I have lost some weight and my A1C has dropped from 9.5 to 6.5 but I am having a lot of lows ranging from upper 40’s to 60’s. I am wondering if maybe I might be able to get off insulin. I feel that my oral med is starting to work better now that my beta cells have had a rest. Can that be true?
    A: Yes, your cells are also in a better position to uptake glucose from the bloodstream now that you have decreased body fat. You should see your physician ASAP to get this adjusted. 40’s are a dangerous range to be in. He/she may start weaning you off insulin, watching your levels along the way.

    Q: How much is blood sugar decreased for every unit of novolog insulin?
    A: A starting point is to consider that one unit of insulin will lower the glucose 50 points. This can vary from 30-100 points, depending on one’s insulin sensitivity, exercise habits, food choices or other variables. Time will tell for you as you test and track your numbers to see if a pattern evolves.

    Q: What medication is used to replace metformin when liver enzymes are high and the endocrinologist discontinues this medication?
    A: Much will depend on the advancement of your diabetes and other medications you might be taking. Your physician might choose a meglitinide such as Prandin or an alpha-clucosidase inhibitor such as Precose. Insulin would be another choice. There are other meds and newer ones always in the mill. Some physicians keep their patients on Metformin if the enzyme levels are not too high. If your numbers are not too high and you are otherwise healthy, focus on lifestyle management. Losing body fat, if needed, can help to get things under control.

    Q: My bottle of insulin will expire next month. Can I still use it or do I need to throw it away?
    A: Expiration dates usually have a grace period. If stored properly, you should be fine. I would assume that your insulin would also be used up sometime around the expiration date. Just to be sure, inquire from your pharmacist or source of your insulin what they advise.

    Q: A lot of times I’ll forget to take my insulin before eating, especially when I go out to eat. Does it help any to take the shot after I’ve eaten?
    A: Yes, if you are referring to short acting insulin. Of course, this will depend on how long after eating you are referring to. Your food may peak an hour after eating, especially if you ate carbs. I suggest you work out a scale or insulin adjustment schedule with your physician. Generally, 1 unit of insulin is geared to lower 15 grams of carbs. It may take a few guided trials for you to learn how your blood sugars respond to insulin taken post-meal.

    Q: When injecting insulin, are you supposed to rotate within the site or rotate sites?
    A: You can do both. The best injection site is abdominal, rotating at least an inch away from the navel. The second best site is the “pinch” of the upper arm. Thighs can be used prior to sleeping. It is best to spend at least a week rotating in one area before moving on. If you can stay with the abdominal area, that would be ideal.

    Q: Is it more effective if I take my insulin in the morning instead of the evening like I do now?
    A: This depends on the type of insulin you are on. If it is a basal insulin, it is often suggested to be taken at night. Even though there is not a peak with basal insulin, it cannot perfectly mimic our physiology; some get better control with the night time dose. Sometimes, it is trial and error to see whether morning or evening works better; sometimes both an a.m. and p.m. injection get better control. Check with your physician to determine when the best injection time is for you.

    Q: I am going to have to switch my insulin because Novo Nordisc is taking their Novolin N and R products off the market. I am not sure the pen is the best for me because once my insulin peaks my blood sugar drops very quickly. Do you have any suggestions for insulins I should research and ask my doctor about?
    A: Have you and your physician discussed using a basal insulin to better balance those peaks and valleys that can occur with intermediate acting insulin? I would assume your physician is abreast of the changes and would begin to have an alternative plan for you. When switching insulin, it may take some closer management for a time as no two companies have the exact same formula. If one is accustomed to taking the R separately, a combo pen is not the best substitute for reasons you note; the control cannot be as exact since combo pens are set ratios.

    Q: At my last appointment my doctor said to take 1 or 2 doses of metformin as necessary. If I take just one pill, my morning and evening readings are 100-120. If I take two pills, the readings are more in the 80-110 range. Is it better to eliminate some medication at the expense of higher readings?
    A: If you are actively following a healthy lifestyle and losing weight if that is part of your program, the single dose may be just fine in the short run while you see lifestyle interventions achieve some more lowering. If you don’t exceed 120 daytime, that is great! If you have no other cardiac conditions, then the single dose may be preferred. Be sure your physician gives you glucose levels to target.

    Q: I am on metforim for type 2 diabetes. It has improved my glucose levels from but I am wondering if this is too much medicine and if it might cause kidney problems!?
    A: All medications have potential side effects. When on metformin, you should be getting you liver enzymes checked every 3 months, at least initially making sure you are stabilized. This is a great time for you to truly start a Healthy Lifestyle Plan, working towards reducing excess body fat if that is an issue. It is possible to reduce/stop medication and there are those who have successfully been able to keep blood sugars in range without medication. Get whatever assistance you need here if you are unclear about whole foods eating and an active lifestyle. There are nutritional supplements that are also helpful. What is best for you will depend in part on any other health conditions/medications you may be taking. With patience, focus, and time spent to learn about your condition, you should certainly make progress.

    Q: Does injecting insulin into the stomach cause additional fat to accumulate there?
    A: Fat deposits do tend to increase where one has the greatest aggregation of fat cells, which for many, is in the belly. The increase would come if one is gaining body fat. Insulin does have a job of depositing the byproducts of both protein and fat digestion into the cells, along with glucose: the end product of carbs. If your caloric intake exceeds your activity output, you will gain fat and it will most likely show up in the belly. What one may experience is some hardening of the tissue in the belly if injections are administered over a long period and are not routinely rotated in the area. Still, abdominal injections are the most effective.

    Q: I have had type II diabetes for 15 yrs. I have been working very hard at diet and exercise and have lost 20 pounds. Three months ago my A1C was 6.8. and now it is 7.9. The doctors want to put me on insulin now. Is there any other oral meds that I can take before I have to go this route? Right now I am taking Metformin 1000mg 2x a day, Glyburide 5mg x 2 twice a day and Avandia 4mg 2 x a day.
    A: At this point, they have about maxed you out on your existing oral medications. I think going on a term of insulin would be wise, in order to give your insulin producing cells a rest and possibly regroup a bit. People have “needle fear”, but when done in the fat of the belly, insulin injections are not painful. Insulin is generally less toxic to the system and has fewer side effects than the oral meds you are taking. Try to get back in that good control you were in, and remain very diligent about lifestyle. Learn carb counting initially and, in time, you will begin to know what affects you and what doesn’t. As you continue to lose body fat and become leaner, you may find yourself needing less insulin. Keep a fish/veggies diet focus, and you will achieve faster results. You may need a tune up with a knowledgeable diabetes educator/nutritionist if unclear about whole foods eating and truly nutrient dense foods.

    Q: Is it possible for someone with insulin resistance to take too much insulin? I am finding it necessary to gradually increase my daily injections of Humalog 25/75 to have satisfactory blood glucose readings.
    A: Pre-mixed insulin cannot give the same fine tuning control that taking baseline/meal insulins separately can. I would assume you are getting low blood sugar reactions? Speak with your physician if this is the case. If you are willing to take your insulins separately, then you should be able to calibrate with your meals more effectively. This will mean learning to count carbs, which is good knowledge to have regardless.

    Q: When on an insulin pump, is it alright to eat anything you want? My teenage stepdaughter who is visiting us right now eats more sugar than I’ve ever seen anyone eat and when I asked her about her sugar intake, and her response was, “It doesn’t matter, I have the pump”.
    A: It certainly does matter how one eats with or without the pump and, in general, with or without diabetes. A pump does allow for a bit more leeway, but not a total sugar binge. In general, more teens are surfacing with conditions never before seen until later stages of life: high lipids, blood sugars and irritable bowel, to name a few. If she is to be living with you, then you would need to become more “proactive”. It may be that if you don’t see her that often that she is “playing” you like a substitute school teacher, getting away with whatever she can while she can. Be very clear about how she normally eats, and what her education and support is. Perhaps you might just consider bringing only healthier foods into the house. If you and others are eating the sugary foods, she, like any 13 year old, does not want to feel “abnormal”. Nothing like a good example to set the stage for change.

    Q: I take novolog 70/30 before breakfast and dinner. My bedtime blood sugar reading can go as low as 37 but then, first thing in the morning, I am up into the 200’s and 300’s. Do I need to switch my insulin?
    A: I would suggest you discuss with your physician about switching to basal and mealtime insulins, which would mean more injections, but better control. In my experience, many folks require more insulin in the morning, because hormones kick in around dawn and tend to elevate blood sugars first thing in the morning. A basal insulin, taken once a day, gives you a better steady “trickle”, then depending on the time of day and the meal, injections in different amounts help to give better control. This is where learning to count carbs, based on 1 unit insulin for every 15 grams of carbs, is a place to start. Over time you can fine tune the amounts once you know the composition of your meals and have a good handle on what you are eating and how much. This may take some homework for awhile, but is well worth it in the long run.

    Q: What does it mean when a person has high insulin levels? Is this bad and what can it cause?
    A: High insulin levels are often the result of years of less than desirable lifestyle habits such as poor food choices. Refined foods, especially carbs, produce sugar very quickly in the body, resulting in the pancreas secreting insulin to meet the demands of removing sugar from the bloodstream. In time, the insulin secreting cells get tired and stop working effectively.

    Q: Could taking an anti-fungal medication cause my blood sugar levels to go too low? I have a toenail fungal infection and was prescribed Lamisil tablets. After 7-10 days of starting the Lamisil, my glucose levels started going very low and I had to reduce my insulin significantly to avoid hypo’s. The problem is that although my readings are within a good range, have become extremely tired and have no energy.
    A: You may be responding to the rapid shift in blood sugar levels, which can be fatiguing. You should adapt. If not, and nothing else has changed in your management, then it may be the medication. Ask your physician about this. As for dealing with future recurrences of the fungal infection, it may help to keep a good amount of fiber in your diet, drink lots of water, take a minimum a high quality multivitamin that suggests 2 pills/day, and one-two courses (bottles) of a probiotic which contains live bacteria that you find in yogurts.

    Q: Is Glucovance causing my blood sugar to go too low? Since I have lost weight, my blood sugar goes as low as 70, which makes me very sweaty and faint.
    A: The good news is that you probably don’t need the medication now! Your efforts are paying off. You may be over medicated which could be dangerous by causing very low blood sugar levels. Notify your physician immediately to start cutting back with the goal to be total elimination of the medication.

    Q: Is my blood pressure medication causing my blood sugar level to drop drastically each morning after I take it?
    A: If you have not changed anything else in your diabetes management, you are most likely being affected by the blood pressure medication. Certainly your physician should be notified, and either recommend a medication change, and/or lower your diabetes medication.

    Q: What could happen if someone were misdiagnosed as having diabetes and took insulin but didn’t need it?
    A: If a person doesn’t need insulin, and is injected with it, there’s a strong possibility of getting a very low blood sugar reaction, depending on the insulin dosage and the amount of food eaten. I personally have never heard of someone being misdiagnosed with diabetes. Before a person is started on insulin, a diagnosis of diabetes is clear via lab tests, and usually, blood sugars are high even with oral medications and lifestyle changes. In and of itself, insulin is not generally damaging.

    Q: Can anti-inflammatory medications increase my blood sugar levels? I have been taking 600mg Ibuprofen 3 times a day and my sugar levels are the highest they have ever been.
    A: Most likely the inflammation itself is the first cause of blood sugar rise. NSAIDs (non-steroidal anti-inflammatory drugs) as a group are hard on the digestive tract over a long haul; this may affect your metabolism at some level. If this is short term for you and not a chronic treatment, you should return to better control as the inflammation subsides.

    Q: I have type 1 diabetes and am wondering if I can take steroids for about 2 months?
    A: Taking steroids is never considered without risk and I would strongly suggest you do not unless advised by your doctor for medical reasons. You can most likely expect the steroids to cause a rise in your blood sugars. Steroids when taken as a prescription often induce secondary diabetes. I am assuming that you are inquiring about steroids for muscle building. As an alternative, you may want to try a microfiltered whey protein powder w/o preservatives, sucralose, or other additives in it. This should be done under nutritional supervision to ensure a good dietary balance. Close monitoring of blood sugars is necessary.

    Q: Is an increase in the amount of insulin that I require a sign that my diabetes is getting worse? I have been a diabetic going on 18 years and most of the time my blood sugar has been anywhere from 200 to 450. When I was first diagnosed, I took 5 to 10 units of insulin but now I take 15 units to 50 units depending on how high my sugar is.
    A: In general, long standing diabetes where blood sugars run high can invite complications. Are you under close care of your physician where you are monitored every 3 months? High blood sugars may to due to many factors. Once diet/lifestyle are truly being well managed and blood sugars are still labile, it may be that forms of neuropathy have taken hold. Please do visit your concerns with your physician.

    Q: What medication can be taken by a type 2 diabetic with leg ulcers, to offset arthritic pain in the foot?
    A: This is a question for your physician. One has to always be aware of drug interactions, depending on your other medications. Better healing is connected to how you eat and if you are taking any nutritional supplements. If there is room for improvement in the health of your lifestyle, I suggest you get some guidance from a nutritionist /diabetes educator. You sound as if your conditions have progressed; it is important to do what you can to slow any further degeneration. A vitamin B-complex may be helpful, as well as fish oil capsules. Certainly taking a high quality multivitamin would be a basic start.

    Q: Is my doctor correct to put me on Byetta for the principle reason of improving beta cell production and longevity? I am resistant to going on it because of the fact it has to be injected and I don’t want the side effects of nausea, gastric upsets, etc.
    A: As with any approved medication, it is only as effective as what we know of it to date, and every person does not respond to each medication the same way. It may be that your doctor’s objective is to discharge you from one or more of your current medications, to Byetta. That is a decision the two of you must arrive at. It is always a good goal to strive towards medication dosage reduction. Perhaps this may occur with a proposed change. All medications do come with warnings.

    Q: Do you agree that although lab standards say I am right in the middle of “normal range values” with a C-peptide at 2.5, half my B-cells are gone? What would be an optimal C-peptide score? My current A1C is 5.9.
    A: A normal fasting level of C-peptide is 0.78-1.89 ng/mL. At 2.50 I don’t know of the correlation to amount of beta cells remaining. If you stay at that level, your lifestyle is managed well, and your blood sugars stay fairly consistent to reflect your 5.9 A1C, I’d say you are on a quality life path, doing what you can with what is in your control. Insulin and C-peptide are jointly secreted, with C-peptide being used as a clinical monitor of your body’s insulin production. Direct measurement of insulin is difficult because it is rapidly removed from the bloodstream. This may make it difficult to rely on C-peptide to accurately measure insulin levels at the time of testing. C-peptide is not an average measurement as is the A1C, (the A1C is the average level of blood sugar over 3 months). They are 2 separate values, and reviewed independently.

    Q: Could I have gotten diabetes from taking prednisone? I am 39 and was diagnosed with diabetes about a month ago, all my symptoms (thirst, frequent urination, dry mouth etc.) started after having 2 steroid shots for a sore throat and then I was on prednisone for my back. My sugar was over 425. Now in the morning it is around 103-120. After meals it is 148-193. How long will it take to get normal?
    A: I wish I could give you a definitive answer, but I can’t. Yes, prednisone can be a trigger for diabetes, and with following a healthy lifestyle, diabetes can be resolved to more normal blood sugars. Certainly, you are reporting much better blood sugars, in the pre-diabetes range. I suggest you discuss this with your physician, and if needed, be referred to an endocrinologist for some more definitive answers regarding the endocrine system and what may be manifesting with you. If you have a family history of diabetes, the prednisone may very well have been your trigger, particularly if you weren’t following a healthy lifestyle. Time will tell; good lifestyle management is a “must.”

    Q: What is the recommended ratio of long term insulin vs. short term to make up the total insulin requirements for the entire day?
    A: Textbook starting point may be 2/3 long acting, 1/3 short or rapid acting. There are formulas to further refine the breakdown. Individualizing each person’s therapy is always the key, based on accurate blood sugar records. Seeing your daily numbers lets you know how well your program is doing and where adjustments need to be made. Remember: no two people with diabetes follow identical management patterns.

    Q: Why do my insulin injections hurt so much? No other diabetic that I have ever met has experienced this as I have.
    A: Have you spoken with your physician about this? It could be that you have a degree of autonomic neuropathy, where you are becoming very “nerve sensitive”. There are topical cayenne based creams that may help. Maintaining a high nutrient dense food intake is important; a nutritionist knowledgeable in vitamin/mineral supplements would be your best source.

    Q: Is there a correlation between the Metformin and hair loss?
    A: Hair loss is not typically listed as a possible side effect with Metformin, but can occur due to stress. Diabetes itself can trigger hair loss. Often a good vitamin/mineral therapy course will begin the correction; B vitamins especially are needed for a more balanced metabolism. You may want to see an endocrinologist about this if it persists. Meanwhile, start eating a truly nutrient-dense diet coupled with exercise. The fewer stresses you have, the more balanced your system will become, and perhaps you will achieve normal blood sugars without the aid of medications.

    Q: Why is my 13 year old son suddenly getting up in the middle of the night with low blood sugar? He eats at exact times and makes sure I do the insulin or check it to make sure that it is accurate. He uses Humalog and Humulin N.
    A: This is due to the peak times of his insulin. It sounds like he needs that dose lowered, which is a good thing. Have you discussed this with his physician? It may be that a switch to a long-lasting insulin like Lantus would be better for him; it certainly is worth exploring.

    Q: Is my diabetes medication causing headaches? I’m not sure if it is my new medication (metformin) or high blood sugar, but I have been getting these horrible headaches that stop me from doing anything all day long. My blood sugar ranges from 130-160. Sometimes it is 100 but it seems like when it is closer to 100, my headaches are even worse.
    A: It does sound like you are reacting to the medication; side effects the first 2 weeks are not uncommon. If this persists, you may need a medication change. You should also let your physician know. It will take some time and patience on your part to accept and understand your diabetes. Each person responds differently. Do not be timid to ask for guidance. I suggest you seek out a diabetes educator, classes, or some other support group to help you along. Paying close attention to your total lifestyle is key to good management, and possibly reducing or eliminating the need for medication.

    Q: Does insulin cause weight gain? I have been on insulin for 4 months and injecting in my stomach and now my stomach has gotten bigger.
    A: Insulin can contribute to weight gain which is one good reason for working on maintaining a healthier lifestyle as much as possible. Weight gain is sometimes also seen when one experiences low blood sugars from too much insulin, and eats more to compensate. With patience and adjustments, insulin requirements can be arrived at. I suggest you get assistance with your diet and carb counting if you haven’t already.

    Q: What kind of medications are used to treat pre-diabetes?
    A: The best “medication” is be as active as you possibly can and follow a healthy, whole foods eating program. Medications are never the magic answer and should only beconsidered when truly needed. A strong focus on lifestyle changes – which usually means losing fat and becoming leaner – can serve to keep most folks under control.

    Q: What do you know about a new “I-Port” that can be implanted into a person with diabetes to give insulin?
    A: Check out the web site for more information. This just involves inserting the dome shaped port onto the injection site via a needle guiding a tiny cannula (tube) into your subcutaneous tissue, where it remains for 3 days. This is similar to the set ups for insulin pumps. For those doing multiple daily injections, this may reduce them by as much 90% in a month.

    Q: My doctor wants to put me on Byetta, for the principle reason of improving beta cell production and longevity. Do you agree that although lab standards say I am right in the middle of “normal range values” with a C-peptide at 2.5, half my B-cells are gone? What would be an optimal C-peptide score? Would Byetta actually do what the doctor says: to help maintain B-cell integrity and functionality? I am resistant to going on it because of the fact it has to be injected and I don’t want the side effects of nausea, gastric upsets, etc. My current A1C is 5.9.
    A: A normal fasting level of C-peptide is 0.78-1.89 ng/mL. At 2.50 I don’t know of the correlation to amount of beta cells remaining. If you stay at that level, your lifestyle is managed well, and your blood sugars stay fairly consistent to reflect your 5.9 A1C, I’d say you are on a quality life path, doing what you can with what is in your control.

    Insulin and C-peptide are jointly secreted, with C-peptide being used as a clinical monitor of your body’s insulin production. Direct measurement of insulin is difficult because it is rapidly removed from the bloodstream. This may make it difficult to rely on C-peptide to accurately measure insulin levels at the time of testing.

    C-peptide is not an average measurement as is the A1C, (the A1C is the average level of blood sugar over 3 months). They are 2 separate values, and reviewed independently. As to your question regarding Byetta, I don’t have an answer for that. As with any approved medication, it is only as effective as what we know of it to date, and every person does not respond to each medication the same way. It may be that your doctor’s objective is to discharge you from one or more of your current medications, to Byetta. That is a decision the two of you must arrive at. It is always a good goal to strive towards medication dosage reduction. Perhaps this may occur with a proposed change. All medications do come with warnings.

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