One Pill At a Time

Which is a better way of treating people with Type 2 diabetes: Starting with one medicine and adding more, or starting with multiple medicines and lowering doses or subtracting meds?


I’m a proponent of beginning with multiple medicines that target different areas, getting the blood glucose down, then lowering doses and/or subtracting medicines. I blogged about this in 2008, but had previously written about it in 2004, based on an interview with California-based endocrinologist Allen B. King, who calls the method “Blast and Taper Fast.”

King explained that it takes more medicine to bring a high blood glucose level down than it does to maintain a normal level.

Depending on the person’s fasting blood glucose after undergoing a two- to six-week period of increased activity and eating changes, he hits them with up to three different medicines. And if their glucose isn’t down to normal levels in two weeks, they’re on insulin.

Wow! Your glucose is coming down. In fact, you’re doing so well the doctor is taking medicines away or, at least, lowering the doses.

Now let’s go to the United Kingdom, where researchers looked at the records of 81,573 people with Type 2 diabetes. Records were in the UK Clinical Practice Research Datalink. Findings were published online in Diabetes Care on July 26. You can read an article about it here. If you have a subscription to Diabetes Care, you can read the original.

Those who had an HbA1c of 7% at baseline had to wait a median of 2.9 years for doctors to add a medicine. By then, their HbA1c was an average of 8.7%. (Median means that half had a lower number and half had a larger number.) It took more than seven years for them to be put on insulin.

Because Type 2 is progressive, treatment needs to be more aggressive as time goes on.

“A substantial proportion of people remain in poor glycemic control for several years before intensification with oral antidiabetes drugs and insulin,” the authors were quoted as writing.

Anyway, and so it went. Sometimes the times and HbA1c results were a little less, sometimes a little more. Doctors waited as patients’ control got worse, putting them at higher risk for diabetic complications.

Researchers were quoted as saying that a

protracted period of poor control can have adverse effects; the follow-up data from the UK Prospective Diabetes Study (UKPDS) have demonstrated the beneficial legacy effect of good glycemic control early in the course of Type 2 diabetes, potentially conferring protection against, or delaying, long-term diabetes complications.

I believe this also makes the case for Type 2s checking their blood glucose. If you see your numbers going up, you can let your doctor know.

Your doctor isn’t the one who feels like crap because of high numbers. Your doctor isn’t going to get retinopathy, kidney disease, neuropathy, have limbs amputated or any of the other, many, diabetic complications. (Remember: Diabetes only affects the parts of your body that have blood flow.)

Insurance and Medicare cover strips if you have a prescription. I didn’t know that in the beginning, nor did my doctor, and I paid out of pocket. You can get store brand meters and strips at places like Walmart and Walgreens. The meters don’t have the bells and whistles the newer ones have, but they work.

You can get a good snapshot of how your numbers are running by checking only two times a day. On one day, check before breakfast and before dinner. The next day, before lunch and at bedtime. Keep alternating.

Occasionally, check two hours after you take your first bite of a meal. I told a man to do that after he said his glucose was about 130 mg/dl every time he checked – every Saturday when he woke up. The next time I saw him, he was in shock. He was from India. I knew he probably ate a lot of rice.

OK. Get yourself educated. Check your BGs. Don’t let your doctor wait to intensify your treatment if your numbers indicate you need more oral medicine or insulin. You haven’t done anything wrong: It’s that darned Diabeastie rearing its ugly head. Again.

Learn more about the health and medical experts who who provide you with the cutting-edge resources, tools, news, and more on Diabetes Self-Management.
About Our Experts >>

  • Mary G

    Interesting article. It could be an viable option for some people, but I would only use this approach with great caution and not as a “first” approach for everyone. I was treated this way when I was first diagnosed Type 2 five years ago. Multiple meds, insulin, the works. It did bring my A1c down from 11.7 to 6.8 in two months, but I felt wretched!!!! Too much was going on! No mention of lifestyle changes. My doctor was never satisfied and added glipizide, which gave me so many lows that I woke up in the middle of the night sweating, ravenous and shaking! I gained a lot of weight. Her response was that my A1c was still “6.1 or 6.2” and she wanted to raise the dosage while instructing me to lose weight!!! She had no intention of “reducing” the meds, so, I decided to educate myself and eventually switched doctors–three times–until over time I was able to find what worked for me. I have adopted a mostly organic, low carb diet and added targeted supplements, including Berberine. It takes diligence, but I am now off all diabetic prescriptions and my last A1c was 5.8. Needless to say, me and my pocketbook feel a whole lot better!

  • jim snell

    Jan: timely pertinent article. Took me 26 years to get to the point I now do all the steps you recommend about diet, learning, advocating your own case and pushing to get mess under control.

    I am on insulin now, wish I started there, and finally under good control and understand how to do all that.

    This is a multi-organ/multi hormone system and I expect that as we get to the 23rd century of Star Trek, our doctor will have a tool kit of drugs and analysis tools that helps hime tune the complex system and adding the drugs/hormones along with diet, exercise et all.

    This complex system cannot be tuned one drug at a time and in my opinion there is no one unified field-signle drug solution that fixes this mess.

    Excellent article and thank you for jumping on this.

  • JohnC

    I agree with Mary..
    Perhaps the Doctors are the ones that need more real-world education. It has been a long time but I still feel the rage thinking of what so-called professionals tried to do to me. They almost succeeded until I decided to get more education.

    A lot of the article sounds like it could have been written years ago..

  • Deb

    I,ve been T2 for 5 years and have been on increasing doses of medication until now I’m taking 1000mg of metformin 2x daily, 100 mg of januvia and for the past 2 years, 15mg of actos. My BG’s were always 7 and higher until I started Actos. Now they have been in the low 6’s and high 5’s. All my other problems have fallen in line ,too- High BP,triglycerides and cholesterol. My high Am BP’s are within the 120 range as long as I take my meds at 6-8AM amd 3PM.
    Now my dr wants to take me off Actos because of high reported incidences of kidney failure. I tend to agree with her but I worry my BG’s will go back up. Is insulin my only other choice to avoid complications? I also worry about more weight gain.

  • Deb

    In the above post I erroneously said by BG’s were in the 5,6, or 7 range. I meant my A1c’s. Duh!

  • Mary G

    Hi Deb–
    Oh, how I feel your pain. You have done so much to try to keep your BG in a good range. I would get off anything that stresses your poor kidneys, so by all means, DITCH THE ACTOS. Also, there is an increased chance of getting pancreatitis and pancreatic cancer with Januvia. It’s not worth going on dialysis or worse just to achieve your doctor’s MAGIC number (remember these numbers keep changing–making you and the doctor think more drugs are needed to achieve these new “numbers”). That said, there are many things you can do in the meantime to normalize your BG levels. Have your insulin levels checked, not just your A1c. This will give you the BROADER picture as to what’s actually going on. If you are making enough insulin, then you need to address WHY you are insulin resistance and look into it’s causes. Metformin addresses this issue pretty well…but, I would take the “ER” version(extended release) as it’s easier on the digestive system. Be aware that some of the drugs you are taking PROMOTE WEIGHT GAIN (but not metformin generally). This is sure to aggravate insulin resistance…just what a diabetic needs!! Ditching sugar in all it’s forms (including honey), avoid regular and diet sodas,simple carbs including white rice, bread, cereals, cakes, cookies, etc.,add good fats such as unsalted almonds, walnuts, pecans, peanuts,etc. and and ounce of very dark chocolate, and use stevia to sweeten, helps to keep your BG numbers in check. Also eat lean proteins such as chicken, fish, peanut butter, plain yogurt,all kinds of vegetables–except starchy ones(sweet potatoes are o.k.),and fresh blueberries, strawberries, rasberries, cranberries, etc. You may need to test your BG more often at first, especially and hour or two after meals to see if a particular food is causing any spikes. Get adequate rest and exercise–walking is a great start!. Targeted supplements such as cinnamon, berberine, chromium,and others may make all the difference…of course, work with your doctor as your need for prescription drugs may be reduced and you need to check for any interactions…grapefruit being a big culprit. The quicker you can get off the drugs, the better the chance of preserving pancreatic function. If you find you are not making adequate insulin, then you need to know that drugs like Januvia, Actos, glipizide, and others are designed to squeeze out the last remaining drops of insulin you are still making.Over time your pancreas will “burn out” and you will need to go on insulin. This is not to scare you but to motivate you into exploring other options then the BIG PHARMA route that your doctor promotes because that’s all he/she was trained to do. Your concern over Actos is well founded, and your stopping it may be your first step to success…it will serve to motivate you into searching what works for you as no two diabetics are alike–so don’t accept the “cookie cutter” treatment! It can be done! But don’t despair…even these steps may not be enough to lower your BG…but you will know you gave it all your effort. You still have the option of going on insulin. This does not mean you failed.!!!! But remember to keep up with the low carb, lean protein, “good fats” diet, exercise, and adequate rest so you will probably need less insulin!