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Discussion Starter · #1 ·
73 yo man diagnosed with DM2, high BP and high
cholesterol in the 2000s. All controlled
with medications ever since.

In the diabetes case:
Metformin 3x500mg/day
FG <126 range
2hrPPG in the normal range
A1c 5.9%.

Recently and without any changes
FG inched up into the 130-150 range, while
the 2hrPPG remains normal (in test: 97 after
piece of cake).

Any ideas/suggestions?

Thanx.
 

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Hi. Welcome!

Any other condition come on or deteriorate in that time? Life situation stable (that is, no new major stressors)? Any significant changes in eating habits (snacks before bed, alcohol or caffeine consumption), etc.?
 

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Discussion Starter · #3 ·
Hi. Welcome!

Thanks for replying.

Well, after 1+ year of pandemic it's hard to say there has been no stress and some changes in diet, but throughout the pandemic when they were greatest the FG was stable @<126 and it inched up now, AFTER the pandemic? Also,
it affected the FG without affecting the 2hrPPG too? Does not seem logical.

I increased Metformin from 3x500 to 4X500 but no effect yet. I have some stomach issues, so if the increase persists,
does it justify adding another med -- I am reluctant as they all have drawbacks.
 

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sgeneris said:
Well, after 1+ year of pandemic it's hard to say there has been no stress and some changes in diet
Ain't that the truth? 😐
sgeneris said:
but throughout the pandemic when they were greatest the FG was stable @<126 and it inched up now, AFTER the pandemic? Also,
it affected the FG without affecting the 2hrPPG too? Does not seem logical.
I always hesitate a little before using the word "logical" around "diabetes". Everyone's experience is so different. You'd think with so many diabetics in the world there would be some real constants; there just aren't many.

However, this sentence gets to what I was going after -- that this has not been of long duration and there are no big recent changes to your lifestyle that would account for this.

That said, a lot can go on between your last food and met dose before sleeping. I've found personally that my FBG is better in the morning if I eat a small snack not too long before I go to bed. Counterintuitive, but it seems to be the way my body works.

sgeneris said:
I increased Metformin from 3x500 to 4X500 but no effect yet. I have some stomach issues, so if the increase persists,
does it justify adding another med -- I am reluctant as they all have drawbacks.
I will mention first that there is an extended-release form of Metformin (if that's not the one you're taking now) that may address the digestive issues.

The other thing I have to mention is that none of us here are medical doctors, so we can't offer medical advice as such. We can, however, suggest changes to what you can control (like what you eat) and come up with questions you can ask your primary care provider and/or endocrinologist.

Can you space the Metformin doses differently? If your 2hrpp is fine on the current dose, maybe another one at some time during the day/evening would make a positive difference. Adding another medication is ... well, as you noted, they all have side effects. Better if you can resolve it through what you're eating or the Metformin, whether it's dosage or the timing of when you take it.

There also is the unhappy fact that, as we all get older, stuff stops working as well as it did. Your glucose tolerance seems pretty good if you can eat cake and have that kind of reading later, but it's possible something else either is increasing a need for insulin, making the body less sensitive to what's being produced, or the regulation of the balance is not what it used to be. What does your PCP say or have you asked yet?
 

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Discussion Starter · #5 ·
I've found personally that my FBG is better in the morning if I eat a small snack not too long before I go to bed. Counterintuitive, but it seems to be the way my body works.
I came across that too and rarely do I go to bed without something to eat a bit earlier.

I will mention first that there is an extended-release form of Metformin (if that's not the one you're taking now) that may address the digestive issues.
Yes, I know, I even tried it, but there was a problem with it: I was eliminating it whole shortly after taking it due to some stomach issues.

The other thing I have to mention is that none of us here are medical doctors, so we can't offer medical advice as such. We can, however, suggest changes to what you can control (like what you eat) and come up with questions you can ask your primary care provider and/or endocrinologist.
Of course. I would do nothing without checking with my dr, although the quality of care I have access to is, well, not the best. So I thought of benefitting from the experience of others.

Can you space the Metformin doses differently? If your 2hrpp is fine on the current dose, maybe another one at some time during the day/evening would make a positive difference. Adding another medication is ... well, as you noted, they all have side effects. Better if you can resolve it through what you're eating or the Metformin, whether it's dosage or the timing of when you take it.
It's actually worse: I am already taking about 10 meds and nobody knows what the interactions and long term effects are.

From the start in 2000 I've always been taking 3x500/day. Yet the FDA guidelines say up to 2000 ONCE a day with evening meal. Does this mean it should be released all at once rather than gradually? Now that I've increased it to 4x500, I wonder if switching to 2000 once would make a difference, but wouldn't it shorten its action? OTOH, wouldn't ER be the same as 4x500?

If I knew what raised the FG but not the PPG, perhaps I could figure out what to do without adding meds. If there is enough insulin to tackle the PP, why is the FG up?

There also is the unhappy fact that, as we all get older, stuff stops working as well as it did. Your glucose tolerance seems pretty good if you can eat cake and have that kind of reading later, but it's possible something else either is increasing a need for insulin, making the body less sensitive to what's being produced, or the regulation of the balance is not what it used to be. What does your PCP say or have you asked yet?
Right, but If there's less sensitivity to insulin, shouldn't it affect both the FG and PPG?

Let's just say that "the quality of my care is not the best" is the understatement of the year. That's part of the reason I am here.
 

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Understood. We'll help as much as we can.

The one thing I'll point out right now is that Metformin accumulates in the body to a certain degree. Missing a dose does not cause the amount in your body to plummet. If you are having stomach issues with 3x500 or 4x500, though, I'll guess that 1x2000 is not going to work well for you even if it does the job diabetes-wise.
 

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Hi sgeneris, welcome to the forum.

In regards to your OP question, its hard to say what might be going on exactly but could be logical. Possibly your phase 1 insulin response isn't working as well as it has been, and now your 2nd phase response is working a little harder to try to keep your BG at its happy place. At 2 hours PP your BG is where it has been, but what was it at 1 hour PP? BG spike should typically reach its peak around 1 hour and be back to normal at 2 hours. You could be peaking higher, but 2nd phase is getting it back down by the time you check, yet your fasting is starting to creep up. If like me, you may have been testing prior to eating and at 1 and 2 hours PP a long tie ago when you first started testing but have not done it in a while so no data to support this thought, but it is possible. I thought about insulin resistivity, but tend to lean along with your thoughts on that it seems it should be seen in both readings.

As far as the regular metformin doses, I'd think keeping it spread out over the day would work best, it would somewhat simulate the time release effect of the extended release version. Max daily dose of regular is supposed to be 2550 mg and ER is 2000 mg. I've only taken the regular metformin and don't know if different manufacturers of ER use different intrinsic coatings or not, but could be worth asking the pharmacist about.

Thats just my opinion, but you can take it and a dollar and get a small coffee.
 

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Discussion Starter · #8 ·
What I meant by "stomach problems" is that I probably have IBS (i.e., unrelated to Metformin). AFAIK I have not had problems with the 3x500 to date or after I added 500. My understanding is that the ER has less stomach side effects.

The way I see it I have the following options:
1. 4x500
2. 2x1000
3. 1x2000
4. 1x2000 ER

Question is what are the pros and cons of each, part. in the context of morning FG -- any thoughts?
 

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Discussion Starter · #9 ·
Thank you.

Looks like I need to take a look @1hrPPG and test that hypothesis. I guess the A1c @under 6% for a long time made me relax, but maybe that's over -- I'm curious what the next A1c will be.

The 3x500 has worked out ok for me since 2000 so there should be a better reason to change. I've just read about the differences between Fortamet and Glumetza (2 types of ER) and the latter has no generic so it's out. If Metformin won't help what would be your next step?

I've asked Roche for some control solutions to test the strips and meter, but I suspect they're probably OK. Can stress raise FG from <126 to 130-50?
 

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Can stress raise FG from <126 to 130-50?
Oh, yeah...

Even the meter may be a little suspect. I don't know how reliably you can chart that 126 and what you're testing at now, but meters are allowed to be off by ±15%, so those 126 and 130 readings are essentially the same. In fact, even the 150 is close to within that range. But if you're consistently measuring that jump, it's not likely the meter. Something else is going on.
 

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Discussion Starter · #11 ·
I am well aware of the meter (un)precision -- even studied it in the beginning and had discussions with vendors about it -- they did not inspire confidence.

Exactly. Here's what I used to get regularly (never over 130)

04/19 FG 110
04/26 FG 122
05/03 FG 122
05/04 FG 120

Then I started getting this:

05/10 FG 131*
05/11 FG 132*
05/12 FG 131*
05/13 FG 141*
05/14 FG 113
05/15 FG 126
05/16 FG 130
05/17 FG 125
05/18 FG 130
05/21 FG 148*/142*
05/22 FG 140**
05/23 FG 134*
05/24 FG 127
05/25 FG 131*
05/26 FG 143*/134
05/27 FG 116
05/28 FG 153**/135
05/29 FG 122
05/30 FG 147*/138*
2PP 108/155
05/312PP 97
06/012PP 118
FG 138*

I did not get the asterisked before. Note: not big increase, but a change nevertheless and there are occasional normals. Hard to interpret.
 

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Discussion Starter · #12 ·
Note also the differences between repeats which is in line with what you were saying about meters.
 

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Thanks for the numbers. Yeah, that's why I'm not wiling to write this off to meter variance. You're charting enough, though it would have been nice to see 2hrpp numbers for early May. There's definitely a jump there. It's not huge, but you do want to look for trends and that's not trending in the direction you want.

Does what you eat vary much day to day? For several reasons, I've essentially made my breakfasts and lunches very similar over the days (and most dinners not hugely different from each other), so a birthday party or an occasional visit to a brewery taproom becomes noticeable the next morning and probably puts more stored glucose into my liver (to be released on successive overnights) than I want to think about.

And no lifestyle change you can date back to that first week of May...?
 

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Discussion Starter · #14 ·
Unfortunately you were right: I have not recorded PPG in a long while for the reason I mentioned: the FG and A1C were normal. I am gonna do both 1hr and 2hr for the next few days.

I would say that whatever I eat these days in whole has not changed much over the years, although the pandemic has messed up my diet healthwise, but not necessarily in the direction of more carbs that could have caused this that I'm aware of. The fact is that I've had this diet for years and the numbers were normal. But maybe the chckens are coming home to roost. And no, no outtings, no parties, no social occasions. Almost complete isolation during the pandemic and even before.
But there has been more stress and less movement, however this should have caused gradual change since the start of the pandemic, not suddenly now at the end.
 

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Discussion Starter · #15 ·
Just to make sure you're not missing anything: Let's assume your hypothesis is correct and there have been 1hrPPG spikes that I've been unaware of. Shouldn't they have shown up in my A1c?

Feb 2021 5.9%
Jun 2020 5.7%
Dec 2019 5.8%

Do these look like it?
 

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Let's assume your hypothesis is correct and there have been 1hrPPG spikes that I've been unaware of.
But it doesn't work that way. As a calculated average, A1c doesn't care how you got there. You can be in very tight control ... or not. A BG level of 95 and 105 average out to 100; so do BG levels of 140 and 70. Hitting those extremes, however, is not as good for you as keeping the spread between starting and 1hrpp/2hrpp as small as possible. Your PCP will look at that A1c and shake your hand for doing so well. But if you're monitoring more closely, you'll get a more complete picture.
 

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Doing the 1 hr PP probably won't tell you if there has been a change there without past data, but it could tell you something may be having a different effect on your BG than it used to if the 1 hour PP of some meals is noticeably higher than others but of similar carb content. Did a recipe ingredient change you weren't aware of, does something have more sugar/carbs than it used to?

New batch of strips?? Are they coded??

Dawn phenomenon??

metformin could be 3 X 850 (thats where the 2550 comes from). If met does or doesn't work, further carb reduction. if that didn't get it, and BG was continuing to increase, I'd go for insulin, but that's me.
 

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Discussion Starter · #18 ·
Doing the 1 hr PP probably won't tell you if there has been a change there without past data, but it could tell you something may be having a different effect on your BG than it used to if the 1 hour PP of some meals is noticeably higher than others but of similar carb content. Did a recipe ingredient change you weren't aware of, does something have more sugar/carbs than it used to?
Yeah, I know, but unfortunately I don't have past data. However, another thing it tells me is that I have PPG spikes, be they new, or higher than the past.

New batch of strips?? Are they coded??
Not new. And I must say I have never come across faulty strips, although it's possible.

Dawn phenomenon??
Sorry, not familiar.

metformin could be 3 X 850 (thats where the 2550 comes from). If met does or doesn't work, further carb reduction. if that didn't get it, and BG was continuing to increase, I'd go for insulin, but that's me.
Funny you should say that -- reading about the other meds, I sort of came to the same conclusion. Thing is, I've been lucky for so many years to not need it that I did not keep up with other than to know that are are now many kinds, not just 1-2 injected like when I was diagnosed. I could go for an oral kind -- any idea which would fit my circumstances?
 

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I was on Januvia then Janumet, but after reading about these and other diabetes meds, asked to be put on straight metformin. I personally, would never take anything but metformin and/or insulin. Here is a link to the Bloodsugar 101 diabetes meds
 
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