[e-drug] Metformin and Lactic acidosis (6)

["Horst Herb" <subscriptions@gnumed.net>]

E-DRUG: Metformin and Lactic acidosis (6)
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We have to be careful not to throw out the child with the bath water.

NIDDM is a devastating disease, probably even more so in the developed overfed 
countries where caloric / carbohydrate excesses coupled with physical 
inactivity have created a true epidemic of it.

At the heart of most cases of NIDDM is Insulin resistance. If we overcome 
Insulin resistance early, NIDDM does not develop. If we overcome it in NIDDM, 
we can reverse the process and cure the disease.

While the United Kingdom Prospective Diabetes Study (UKPDS) has shown that this can be achieved in a number of patients  with intensive diet and life style intervention, daily practice is different 
from that study design and providing personal trainers, motivators and dietitians to all cases as they did in the study would probably exhaust the funds of even the wealthiest countries

It is my experience that metformin, given early, together with serious life style intervention, can reverse the disease process in a good majority of patients. Without metformin, I achieve not even a small fraction of the complete reversals in my patient collective, despite having a good dietitian 
and district nurses with an active community program at my disposition.

In the third world, the problems that come with being inactive and overfed are 
less prevalent I daresay, so metformin might not be all that important - but 
for me and my practice in Australia it is one of the most essential drugs. It has helped more than any other drug I can think of to actually prevent development of serious disease and along with this has prevented people from being dependent of medication for the rest of their lifes. If people are insulin deficient, they will depend on Insulin substitution the rest of their lives. If they take metformin in the early stage of NIDDM or in so called "pre-diabetes", the Insulin resistance is often reversible, the problem fixed, and the patient can come off medication. 

This is because the process of Insulin resistance that leads to clinical NIDDM 
(and later on in the process exhaustion of the beta cells with the result of 
Insulin dependent "NIDDM") can be reversed in many cases if we intervene 
early and aggressive enough. 

We just had two such cases again in my practice, confirmed by the endocrinologist in our region 
(patients with previously HbA1c > 8.0 for > 1 year, and now normal 2hr GTT 
result with normal Insulin levels.)

At least in my practice I rarely achieve this goal without metformin - so by withholding it I might condemn a patient to life long dependency on Insulin later in life.

There is simply no alternative - sulfonylureas just drive people deeper into 
Insulin resistance and guarantee permanent diabetes as outcome, glitazones 
have nowhere near the evidence of benefit and are coming now under scrutiny 
regarding their cardiovascular risk - so what else is there to offer?

Horst

Dr Horst Herb
Principal
Dorrigo Medical Centre
Dorrigo, NSW 2453 AUSTRALIA
"Horst Herb" <subscriptions@gnumed.net>