Q: I am a 54 years old male suffering from type 2 diabetes taking Daonil (5 mg) (1/2 tablet in morning before food and Clopilet (75 mg) and Betalac (50 mg) in morning after food. At night, I take Rozavel 10 and Omega 3 (100 mg) after food. Around 10 days back, I underwent blood test, which showed fasting blood sugar level - 139 with Hb1Ac as 7.2 and after food my blood sugar level was 160 (with all medicines). Blood pressure was 90-120 mmHg. Recently, I am experiencing pain in my left hand below my fingers and in my right foot below finger level. Please guide.

A:Daonil (glibenclaimide is a drug used in diabetes to lower blood sugar. Please note that most patients should start with metformin rather than glibenclamide. I would suggest starting metformin first but discuss with your doctor first. Metformin alone should be able to control sugar; if it’s not able to control, glibenclamide should be used. This medication increases insulin secretion from pancreas and may also increase tissue response to insulin. It is safe for long term use and the main risk of hypoglycaemia which can be more common elderly and renal failure patients.

Most oral medication safety concern has been heart side effects but recent reports have shown it to be safe as well. There are no studies which strongly support association of early failure of beta cell of pancreas by oral drugs.

Some other side effect includes headache, dizziness, nausea and very rarely hepatitis and abnormal liver function test. These side effects are not usually seen. If your sugar control is well controlled with oral medication no need to take insulin if sugar control not fine {refer to HbA1c} with combination of oral, then insulin can be added with oral as well. Insulin can be started very early along with just one medication like metformin. Please read about metformin as well on our website.

Medications
Metformin (Glycomet / Glyciphage / Riomet / Carbophage / Cetapin) comes in 2 forms sustained or extended release (SR or XR) or immediate release (IR) or plain form. This is the first line drug in almost all patients those are overweight. This should be continued all your life except you have more than moderate kidney dysfunction (creatinine more than 1.5) or side effects to this medication. This is safest medication and we have used this medication for almost 50 years which was originally extracted from a plant extract. This medication in diabetes is so important than you should ask your doctor about it. This medication is slow acting i.e. it may take weeks before you can notice any significant effect on blood sugar level.

Advantages of Metformin
This controls sugars or normalizes blood sugar with almost negligible risk of low blood sugar (hypoglycaemia). It also reduces risk of heart diseases. It’s suitable in most patients and can be used with any other oral diabetes medication and Insulin as well. This works with most of the other medication in diabetes and also safe in most patients with mild liver or heart problem like heart failure patient as well unlike popular belief.

Dosage
Sustained or extended release (SR or XR form). It should be used to the maximum tolerated dosages as risk of hypoglycaemia is less and benefit is more with higher dosage. We use sustained release formulation (SR or XR) version. We recommend starting 500 mg once a day with dinner and over few days (5 to 7) increase with twice a day which can be taken before or after meals or along with the meals.

Later we usually recommend increasing to 1000 mg (1gm) twice a day. In case side effects occur this can be reduced to lower dosage of 500 mg twice a day.

Immediate release (IR) or plain form
In plain or immediate form of metformin dosage around 500 mg three time a day with each meal (after or just before) starting with one meal and gradually increasing to three times a day, in which can be increased to 850 mg three times a day and well tolerated can be taken, up to 1000 mg three time a day.

Timing of the meal - Along with meal before or after.

Side effects - There are almost no long lasting side effects of this medication. This prevents progression of diabetes rather than make you dependent upon medication. Common side effects are usually in first few days of taking it, later they wear off. This is one of the oldest in use and has the best safety record and beneficial to most patients with diabetes side effect which are common - abdominal pain or discomfort, nausea or vomiting, diarrhoea, not feeling hungry and abnormal taste. These side effects are reversible. If you continue to have side effects than you can reduce to once a day and take after meals with water or reduce the dosage to half. The risk of hypoglycemia (low sugars) is almost negligible as long as it’s not being taken with other diabetes drugs.