Blood Sugar Management: Key Indicators and Medication Options

Blood sugar issues

Dear Dr.
Hsiao,
I have been concerned about my blood sugar levels since my health check in 2004, when my fasting blood glucose was 100.
I only started medication in 2015, but my weight has decreased from my usual 38 kg to the current 34 kg.
For the past ten years, my HbA1c has consistently been below 7.
On February 19 of this year, my AC was 155, PC was 169, and HbA1c was 6.6.
This was after I stopped taking Amaryl (0.5 mg) due to recurrent hypoglycemia after one month of use.
The data I provided is from the two months following the discontinuation of the medication.

I would like to ask you, Dr.
Hsiao:
1.
Which of the three blood sugar indicators is the most important? If my HbA1c remains below 7, should I not be too concerned about occasional elevated AC and PC values, such as those I mentioned above?
2.
My current physician has prescribed Metformin 500 mg, one tablet a day.
How does this dosage translate in terms of units? I am worried about potential liver and kidney issues.

3.
When I started medication in 2015, I was informed through media reports that Trajenta (linagliptin) 5 mg is safe for the liver and kidneys.
My clinic allowed me to take it for six months upon my request, but my current physician says my symptoms do not require this medication.
Is it only prescribed for more severe cases?
4.
I would like to regain my weight but am unsure which blood sugar-lowering medication would be most suitable.
Could you please recommend one, Dr.
Hsiao?
Thank you very much for taking the time to answer my questions.
I greatly appreciate it.

Weng Nüshi, 60~69 year old female. Ask Date: 2016/02/26

Dr. Xiao Yongxun reply Internal Medicine

1.
For a 65-year-old diabetic patient, a fasting blood glucose level of 155 mg/dL, a postprandial blood glucose level of 169 mg/dL two hours after eating, and a hemoglobin A1c level of 6.6% indicate relatively good control.
Each of these values carries individual significance, and clinical evaluation must consider symptoms for a comprehensive assessment to guide treatment.
The hemoglobin A1c of 6.6% is close to the target value of 6.5%, suggesting that blood glucose control has been quite good over the past six weeks prior to the blood draw.
According to epidemiological studies, a fasting blood glucose level is typically around 126 mg/dL.
Your fasting blood glucose level of 155 mg/dL is slightly above 126 mg/dL, possibly due to excessive caloric intake or lack of exercise in the days leading up to the test, which may not have been fully metabolized.
Additionally, the normal range for postprandial blood glucose is below 140 mg/dL.
Your postprandial blood glucose level of 169 mg/dL falls between 140 and 180 mg/dL; although it is higher than 140 mg/dL, it is still below 180 mg/dL, indicating that insulin secretion and blood glucose control are not ideal but still relatively good.
2.
The use of Metformin is currently the first-line medication recommended for the treatment of type 2 diabetes in Taiwan, the United States, Japan, and various European countries.
It can moderately lower blood glucose levels without causing hypoglycemic coma when used alone.
Like all medications, Metformin has side effects, including the potential for vitamin B12 deficiency, the risk of lactic acidosis in patients with impaired renal function, and possible gastrointestinal discomfort or liver function effects after use.
In practice, cases of liver and kidney damage due to Metformin are relatively rare; more commonly, poor blood glucose control leads to conditions like fatty liver and kidney damage.
Therefore, your physician's choice of medication seems very reasonable and commendable.
3.
Trajenta® belongs to the DPP-IV inhibitor class; simply put, it works by inhibiting the DPP-IV enzyme to prolong the insulin secretion triggered by incretins, thereby extending its duration of action to lower blood glucose levels.
Compared to Januvia® and Onglyza®, Trajenta® is considered a newer DPP-IV inhibitor.
Like all medications, it also has side effects, including the more serious risk of acute pancreatitis and various mild side effects such as runny nose, cough, joint pain, and headache.
Other side effects discovered post-marketing are still pending further medical reports.
While this medication is not restricted to severe patients, it is currently not the first-line treatment recommended for type 2 diabetes.
4.
There are many reasons for weight loss, commonly seen in diabetes, hyperthyroidism, cancer, tuberculosis, chronic diseases, depression, and anxiety, among others.
Your weight has decreased from 38 kg in 2004 to 34 kg in 2015; this may be due to diabetes or other factors.
It is advisable to discuss this with your physician regarding whether weight should be regained, how to regain it, and to what extent.
Please address these concerns with your physician for examination and discussion.
5.
Management of type 2 diabetes primarily includes dietary control, regular exercise, and pharmacological treatment.
Remember, do not expect to maintain control solely through medication.

Reply Date: 2016/02/26

More Info

Managing blood sugar levels is crucial for individuals with diabetes, and understanding the key indicators and medication options is essential for effective treatment. In your case, you have been monitoring your blood sugar levels for several years, and it seems you have a good grasp of your condition. Let’s address your questions one by one.

1. Key Indicators of Blood Sugar Control: The three primary indicators of blood sugar management are fasting blood glucose (FBG), postprandial blood glucose (PPBG), and glycated hemoglobin (HbA1c). Among these, HbA1c is often considered the most important because it provides an average blood glucose level over the past two to three months. Maintaining an HbA1c level below 7% is generally recommended for most adults with diabetes, as it is associated with a reduced risk of diabetes-related complications. However, it is also important to monitor FBG and PPBG, as they can indicate how well your blood sugar is controlled throughout the day. In your case, while your HbA1c is well-controlled at 6.6%, your fasting and postprandial levels are elevated. This suggests that while your long-term control is good, there may be periods of hyperglycemia that need to be addressed.

2. Metformin Dosage and Concerns: Metformin is a first-line medication for type 2 diabetes and is generally well-tolerated. The standard starting dose is often 500 mg once or twice daily, and it can be adjusted based on blood sugar levels and tolerance. It is important to note that Metformin is not typically associated with significant liver or kidney damage when used appropriately. However, it can cause gastrointestinal side effects, and in rare cases, it may lead to lactic acidosis, especially in individuals with impaired kidney function. Regular monitoring of kidney function (e.g., serum creatinine) is recommended while on Metformin.

3. Trajenta (Linagliptin) Usage: Trajenta is a DPP-4 inhibitor that helps to lower blood sugar levels by increasing insulin release and decreasing glucagon levels. It is not limited to severe cases of diabetes; it can be prescribed for patients with type 2 diabetes who are not achieving adequate control with lifestyle changes and other medications. If your physician believes that your current symptoms do not warrant the use of Trajenta, it may be due to the fact that your blood sugar levels are relatively well-controlled with your current regimen. However, if you feel that your blood sugar is not adequately managed, it is worth discussing this further with your healthcare provider.

4. Weight Restoration and Medication Options: Weight loss can be a common issue in individuals with diabetes, especially if blood sugar levels are not well controlled. It is important to address the underlying causes of weight loss, which could include inadequate caloric intake, medication side effects, or other health issues. In terms of medication, there are several options available that may assist with blood sugar control while also being more weight-neutral or even promoting weight gain. Medications such as Metformin are generally weight-neutral, while GLP-1 receptor agonists (like Liraglutide) can promote weight loss. Discussing your specific weight goals and concerns with your healthcare provider can help tailor a treatment plan that suits your needs.

In summary, maintaining a comprehensive approach to diabetes management that includes regular monitoring of blood sugar levels, appropriate medication use, and lifestyle modifications is essential. It is crucial to have open communication with your healthcare provider to ensure that your treatment plan is effective and aligned with your health goals. Regular follow-ups and adjustments to your medication regimen may be necessary based on your ongoing assessments.

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