One of my greatest pleasures in life is to help patients achieve remission of their type 2 diabetes. This means their blood sugar levels have become normal in the absence of any diabetes medication.
Many clinicians and patients are interested in learning my views about how to go about decreasing and discontinuing diabetes medications. The main role for medications is to help reduce or delay the risk of nasty complications of diabetes, particularly the damage to the retina, kidney, nerves,and circulation. The higher the average blood sugar level, as indicated by the hemoglobin A1c level, the greater the complication risk (which increases exponentially with increasing A1c).
We know from clinical trials that using medication to keep the A1c at or below 7% can help reduce the risk of these complications. There is broad agreement that clinicians should recommend starting or increasing diabetes medications to patients who cannot get their A1c level to 7% or less via lifestyle change.
Many patients come to me because the A1c is already over 7%, and their primary care provider proposes increasing their diabetes medication, unless the patient can get to 7% or less with improved eating and/or exercise habits. Some of these patients are already on many pills, and insulin shots are the frequently the next appropriate treatment.
Many patients would rather make the lifestyle changes than take more medication, so when the doctor frames the issue in this way, then a patient might become inspired to renew or increase the lifestyle efforts. The clinician might say “let's recheck the A1c in three months, and start the new medication if it is still above 7.0%.”
There can be little doubt that using lifestyle changes to normalize the glucose levels and A1c is a good thing. In contrast, the strategy of driving the A1c well below 7.0% with multiple medications has little to offer most patients in terms of quality of life or reduced risk of complications.
Most patients I see are already taking metformin, which is the preferred second-line treatment after lifestyle change. I typically recommend initiating it in patients with A1c’s of 6.5% who cannot push it any lower via lifestyle change. For patients who are already on metformin, I do not decrease the dose unless the A1c is 6.0% or less. I might reduce the dose by half every three months, as long as the A1c stays at 6.0% or less. I stop the final 500 mg of metformin when the A1c is 6.0% or less for at least three months.
Some drugs can lower the blood sugar levels below the normal range, causing symptoms of hypoglycemia. These drugs, which include insulin and those in the sulfonylurea family (which are common in patients on more than one kind of diabetes pill) need to be reduced or discontinued by the clinician as required to avoid hypoglycemia, so these are typically the first drugs to be discontinued. It is important that patients who take these medications check their blood sugar levels regularly, particularly while making lifestyle changes. Doing so lets us know the risk of future hypoglycemia and guides the decision about when to decrease or discontinue such medications.
In the absence of insulin or sulfonylureas, then other drugs (such as pioglitizone) come off next. I typically wait until the A1c is 6.5% or less to propose stopping such drugs, and would not initiate or re-initiate any diabetes drugs (other than metformin as noted above) unless the A1c is above 7.0%.
So, in summary, ambitious eating and exercise goals are important in all stages of diabetes, and drugs are crucially important in patients who cannot otherwise keep the A1c below 7.0%. It is clear that medications can be avoided, delayed, or discontinued when lifestyle efforts are intensified and sustained. For many (if not most) patients, lifestyle coaching by a clinician, dietitian, personal trainer, peer group, etc. can dramatically increase the odds of success.
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