Metformin insulin combination

In combination with metformin, insulin, or a sulfonylurea when diet, exercise, and a single agent do not result in adequate glycemic control. 

Rosiglitazone - Reports of anemia were greater in patients treated with a combination of rosiglitazone and metformin compared with rosiglitazone monotherapy. Edema was reported with higher frequency in the rosiglitazone plus insulin combination trials. 

Biguanides cause hypoglycemia in 0.24 cases per 100 patient-years and it is more common when they are used in combination with a sulfonylurea (44). In 102 consecutive patients with drug-induced hospital-related hypoglycemic coma, 13 were taking metformin + glibenclamide and 3 were taking metformin + insulin (45). 

Furlong NJ, Hulme SA, O Brien SV, Hardy KJ. Repaglinide versus metformin in combination with bedtime NPH insulin in patients with type 2 diabetes established on insulin/metformin combination therapy. Diabetes Care 2002 25(10) 1685-90. 

A 45-year-old man with type 2 diabetes treated with glibenclamide and metformin received combined chemotherapy for non-Hodgkin s lymphoma and was given premixed insulin. He developed local wheal-and-flare reactions immediately after the injections. Skin prick tests were positive for various types of insulin but weakly positive for lispro and negative for insulin aspart. He tolerated aspart insulin without any allergic reactions. 

Rosiglitazone maleate is a thiazolidinedione that increases insulin sensitivity improves sensitivity to insulin in muscles, adipose tissue and inhibits hepatic gluconeogenesis. It is indicated in improving glycemic control of type 2 diabetes mellitus as monotherapy and as an adjunct to diet and exercise and in combination with metformin, insulin, or a sulfonylurea when diet, exercise, and a single agent does not result in adequate glycemic control in patients with type 2 diabetes mellitus. 

It can be recommended that insulin treatment is combined with metformin. The combination improves glycaemic control and reduces the weight increase after starting up insulin when compared with treatment with insulin alone. The combination with metformin reduces the insulin dose. 

Drug dosage regimens In a systematic review of 26 randomised trials, using a random effects model, the insulin dose was significantly reduced to 5 units per day when metformin was combined with insulin, compared with insulin alone. [12 ]... 

Type 2 diabetes with sulfonylurea, metformin, or insulin to improve glycemic control Type 2 diabetes in combination with metformin to improve glycemic control... 

Other combination options Metformin or a Sulfonylurea plus Acarbose/Miglitol, or Pioglitazone/ Rosiglitazone or Repaglinide (with metformin), or Insulin... 

FPG levels by 30 to 50 mg/dL (1.67-2.78 mmol/L), and the overall effect on HbAlc is a 1% to 1.5% reduction. Onset of action for thiazolidinediones is delayed for several weeks and may require up to 12 weeks before maximum effects are observed. Combining a sulfonylurea, non-sulfonylurea secret-agogue, metformin, or insulin with a thiazolidinedione can improve HbAlc reductions to 2% to 2.5%. 

Several years have passed since you have been following MF s therapy. His weight is down to 230 lb (104.6 kg), and he tries to maintain his diet and exercise. His recent HbAlc levels have increased up to 8.4% from 7.2% despite combination therapy with sulfonylureas and metformin. The physician believes that it is time to start insulin therapy for MF and asks you to initiate therapy and follow his regimen. 

Repaglinide is a newer oral hypoglycaemic agent, indicated in type 2 diabetes either in combination with metformin or as monotherapy. Repaglinide stimulates insulin release. 

Sitagliptin is a dipeptidylpeptidase-4 inhibitor that increases insulin secretion and lowers glucagon secretion. Sitagliptin is available for oral administration. It is indicated in patients with type 2 diabetes mellitus in combination with either metformin (biguanide) or a sulphonylurea or a thiazolidinedione. 

Avandia (rosiglitazone) as with other thiazolidinediones is used either as monotherapy or in combination with either metformin or a sulphonylurea. A disadvantage of rosiglitazone is the risk of heart failure as a side-effect. This risk is increased when rosiglitazone is used in patients with cardiovascular disease and when used in combination with insulin. Blood-glucose control may deteriorate temporarily when a thiazolidinedione is substituted for an oral antidiabetic agent. 

Metformin, a biguanide derivative, can lower excessive blood glucose levels, provided that insulin is present Metformin does not stimulate insulin release. Glucose release from the liver is decreased, while peripheral uptake is enhanced. The danger of hypoglycemia apparently is not increased. Frequent adverse effects include anorexia, nausea, and diarrhea Overproduction of lactic acid (lactate acidosis, lethality 50%) is a rare, potentially fatal reactioa Metformin is used in combination with sulfony-lureas or by itself. It is contraindicated in renal insufficiency and should therefore be avoided in elderly patients. 

Should secondary failure occur with metformin or sulfonylurea monotherapy, combined therapy with metformin and sulfonylurea may result in a response. Should secondary failure occur with combined therapy, it may be necessary to consider therapeutic alternatives, including initiation of insulin therapy. 

Combination therapy - When rosiglitazone is added to existing therapy, the current dose of sulfonylurea, insulin, or metformin can be continued upon initiation of rosiglitazone therapy. 

Pioglitazone - Pioglitazone when used in combination with sulfonylureas, metformin, or insulin caused an increased incidence of edema. 

The patient who would benefit the most from a thi-azolidinedione is a type 11 diabetic with a substantial amount of insulin resistance (e.g., one who does not respond to other oral therapies or who requires excessive amounts of insulin [>100 units/day]). Improvements in diabetic control are variable, ranging from a 1% reduction in hemoglobin Ale when used as monotherapy to greater reductions (>2% reduction in hemoglobin Ale) when used in combinations with other agents, such as sulfonylureas or metformin. 

Rosiglitazone is approved for use as monotherapy and in conjunction with metformin, though it is sometimes combined with a sulfonylurea or insulin. It is usually taken once or twice a day with or without food. Rosiglitazone may cause a modest increase in low-density lipoprotein and triglyceride concentrations, but it is unclear whether this effect has any clinical significance or persists in the long term. 

Diabetes mellitus, combination therapy PO With insulin Initially, 15-30 mg once a day. Initially, continue current insulin dosage then decrease insulin dosage by 10% to 25% if hypoglycemia occurs or plasma glucose level decreases to less than 100 mg/dl. Maximum 45 mg/day. With sulfonylureas Initially, 15-30 mg/day. Decrease sulfonylurea dosage if hypoglycemia occurs. With metformin Initially, 15-30 mg/day. As monotherapy Monotherapy is not to be used if patient is well controlled with diet and exercise alone. Initially, 15-30 mg/day. May increase dosage in increments until 45 mg/day is reached. 

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