From Medscape Education Family Medicine
Intensifying From Oral Therapy to GLP-1 Agonist/Basal Insulin Combinations CME / ABIM MOC
CME / ABIM MOC Released: 9/20/2016; Valid for credit through 9/20/2017
Dr Wysham: Clinically speaking, when and why would it be more appropriate to initiate fixed-dose combination therapy?Clinically speaking .... Ok let us speak clinically.
Dr Buse: The rationale for the use of fixed-dose combination therapy is 3-fold. The first, and most common, is that in patients who are already taking 1 drug of the combination, you can simply add the other.Why to add another drug and do not try to increase dose the medicine which already works well? Every medicine has its own side effects, and interaction one medicine with another can be dangerous. So, why at first do not increasing the dose of medicine which already works but do not provide effect needed to control disease? What if first medicine did not work, then there is no one reason to add any other medicine. Just stop to Rx one which does not work effectively and Rx another one which provide effect needed for recovery of patient. It can be increased dose if it is needed, but still it is not add-on medicine but solo.
Dr Buse: Second, in general, the simultaneous use of 2 drugs provides greater power to reduce glucose and achieve the treatment target goal more quickly than with sequential therapy, which may be a particularly useful strategy in cases where the glucose level is significantly out of control.Personally, I would not take it for granted that two is better then one. But still, I prefer to take into consideration another part of statement, " 2 drugs provides greater power to reduce glucose". We are talking about treatment at home, not about Intensive Care Unit therapy, right? Fast blood glucose level reduction is short time effect but very dangerous. It can be fatal if it left out of control. There is nothing too fast with diabetes. To reduce blood sugar level fast is effective in only one case when blood sugar is high and it must be reduced to safety level. Safely level is not blood sugar control level. It is level of sugar in blood when it is not fatally high. In all other cases medicine must work slow and it is all the time long shot.
In case of presentation there is actress who present patient. As I see, there is another actor who present 'doctor Buse'. I do not see any reason to refer to the actor as 'doctor' so he is simple Mr. Buse.
Dr Buse: Third, the use of 2 agents together minimizes the risk of adverse events associated with the use of either agent alone because, in general, the doses of each agent are lower.How this point is clinical? As doctor Mr. Buse must do know very well, it is active ingredient which provide heeling effect, so it does not matter two types of medicine taken in one shot or in two solo shots the effect will be the same if active dose is the same. Now, if dose of every one agent is less then it is needed then there is no effect, does not matter if medicine taken in one shot or two separate shots.
Now, there is conflict in the statement. So, if two medicine taken in one shot work more effective then one, then say me why negative effect of two would be less then negative effect of two in one shot? To say it, Mr. Buse must provide the prove rather then statement that it will be in this way.
Dr Buse: Specifically, for a patient who is currently at an HbA1c of 8.4%, using insulin and a GLP-1 receptor agonist in combination reduces the nausea and other GI adverse events seen with GLP-1 receptor agonist use and the weight gain and hypoglycemia seen with insulin.There is question to Mr. Buse, why insulin therapy did not provide blood sugar control? We do have patient who takes two types of medicine, insulin and GLP-1 in two separate forms. Now two medicine combined, and so in one shot two would be better then two in solo shots? Is this Clinical Humor? It is diabetes. In diabetes level of sugar different day out of day, hour out of hour, every hour. Two different families of medicine were not able to provide blood sugar control even two are very flexible in dosing and now Mr. Buse pretends that two in one fixed shot are better then two in solo shots? Fixed dose is not flexible. It is not possible to increase or decrease one without effecting another, difference with solo dose of two.
There is another question for Mr. Buse, why insulin did not reduce level of sugar in blood stream that diabetic type 2 moved to HbA1c >8.4%? All what provider needed just add some units of insulin, and do not add any other medicine ether in solo shot nether in combination shot. How it sound 'clinical, that reducing dose of insulin will lead to blood sugar control if two medicine would be taken in combined shot?
Dr Wysham: Thank you, John, this is very practical advice and clarifies a lot. But, returning to our example case, do patients who are taking metformin, even when it is clearly not controlling their HbA1c, resist starting injectable therapy, precisely because it does involve an injection? Do you have any tips for clinicians on how to transition patients from oral therapies to an injectable drug?It is blue dream that diabetics type 2 afraid injections, so this is why medical providers so resistant to Rx insulin therapy. It is presented that to swallow tablet is easy then inject insulin into own belly. Is this really true that tablet is easy then injection? Two doctors have no one idea they are taking about medicine, not about some pleasant food. So, little children take insulin in injections, do they like it or not. With time they understand, it is what they have to do, regardless they do like it or not, so they no longer run away from mammy or doctor. In contrary, adults prefer medicine which does not work such as metformin and reject insulin because they do not like injections? Clinical Humor, not less then that.
Dr Buse: No patient ever says, “What I want is something that I can inject instead of taking as a tablet.” There is always some resistance.
Another point about medicine in tablet vs injections.
When I take insulin soon I feel better and functional. Step by step one after another I stop to take some other medicine because there is no longer need in them. When I take tablets such as Metformin soon I am so dizzy, like I drunk full glass of strong Spirit, vomiting. The same effect with Glipizide. Soon after I take this medicine I am weak, sweat, shaken, and all side effects of low blood sugar. I do not have energy to take any move. My heart rate is high.
At least, but not last, the pain from insulin injection is not the needle how it is small and easy enter into body, but the short pain of medicine injected under skin. This pain can be so sharp, it is almost unbearable. In this case I stop to inject medicine, still keep needle into body, wait till pain eased, and finish the shot. Looks like Mr. Buse have no one idea how painful medicine can be, oral in tablet or in injection. In stead he show to patient that needle is small, and it does not hurt when there is no medicine enter into body. Clinical Baby Talk.
Dr Buse: There is always some resistance. But, as clinicians, we can educate our patients from the time they begin therapy about the progressive nature of type 2 diabetes and how, eventually, most patients will need intensification with additional therapy.Sorry, Mr. Buse. Diabetes type 2 is not progressive by nature. Diabetes type 2 is the same as any other medical conditions, it is treatable and can be cured the same way as we cure the infections or tooth. When left untreated diabetes, the same as infections, flu, bacteria such as TB, can lead to Death. With treatment it can be cured, even it can return after time, the same as flu.
Insulin can treat and cure diabetes, any type of it, in any stage of it. Someone would need insulin injections for the rest one's life, many other would not need it after awhile. The treatment and effect of insulin therapy depends from the dose of it. If dose of insulin right, and type of insulin right, then Diabetes type 2 regressive. With time dose of insulin decreases. It is prove that diabetes type 2 treatable, and our Deaths are 100% preventable. The point is not only about Death, but the rest of our lives we live in misery, in constant pain, disable. This is preventable 100%. But it is insulin in present time, and insulin only which can do the job. No one fixed dose of any combination insulin with Junk Medicine can safe our lives and prevent our disability and misery.
via Ravenvoron
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