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 “lets recheck the A1c in 3 months, and start the new medication if it is still above 7.0%”.
My goal with patients is to use the lifestyle strategies I’ve discussed previously in this blog to drive the A1c as low as possible. I want to push the A1c very far below 7.0%. If possible I would prefer to push the A1c into the normal range of 5.7% or less, and I’ve helped many patients push it close to 5.0%. 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. Opinions differ about when to start this drug. Some experts advocate starting it in patients who have pre-diabetes because clinical trial evidence demonstrates that it can delay the progression to type 2 diabetes, while other experts could argue that there is little evidence that it reduces diabetes complications when the A1c is below 7.0%, so no point in starting it until 7.0% It is important to discuss these issues with patients.
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 3 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 3 months. Once a patient has discontinued it, I would then recommend restarting it if the A1c reaches 6.5%. Other alternative approaches would also be reasonable, and patient and physician preferences should be taken into account when making such decisions about starting and stopping metformin.
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.
For patients on insulin, this type of monitoring is mandatory. Initially, insulin dose reduction typically mirrors dietary carbohydrate reduction, and many patients are quickly using half as much insulin, particularly the short-acting insulin boluses used to prevent hyperglycemia during and after meals. Weight loss often brings additional reductions and sometimes discontinuations of insulin, however the glucose and A1c levels are the key to managing insulin dosing over time. The majority of my patients have not been able to discontinue insulin altogether, although nearly all of them have been able to significantly reduce their dose as well as their A1c levels. The chances of discontinuing insulin are best when the lifestyle adherence levels are high, the weight loss is large, the initial insulin requirement is relatively low, and the duration of diabetes is short, almost always less than 10 years.
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%. Metformin is the first drug of choice whenever possible, and the last drug to be discontinued in patient who normalize glucose levels via lifestyle changes. The A1c levels to start and stop metformin are up for debate, and may be individualized according to patient and clinician preferences. 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.
- Michael Dansinger, MD