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Medical Forum / Diseases and Disorders / Diabetes / October 2005

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Comments on my med adjustments, please

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Dick Malchik - 15 Oct 2005 10:00 GMT
There are some knowledgable people here. Can someone lend a few
minutes?  Summary on top, unnessary rambling below.  ;-)

Complete meds currently taking:

Waking:    450 mg metformin, 2 mg Avandia, 30 mg Diabeton
Lunch:        450 mg metformin
Dinner:    450 mg metformin, 2 mg Avandia
Evening:    450 mg metformin, 5 mg Lipitor

Comments on this new med regime? Any insight would be helpful. Note
I'm in Kiev, Western experienced endos are difficult to find. I'll be
home in the U.S. in December, and will search for a good endo ready
for an appt when I return.

Rich

Brief history:

May 2000 T2 Dx at 44 years, within a few months of full diabetic
onset.  205-210 lbs, 5' 8" light frame.  Dropped almost 70lbs of ugly
fat to 137-145 in 2001. Very busy GP doctor and relatively no diabetic
consultations. Rx: lose weight, 2 mg glimiperide(Amaryl) 1000 mg
metformin(Glucophage) a day.   Almost ANY dose of Amaryl, even 1/4 mg
day, caused hypoglycemia.  Doctor said only "well then, don't take
it."  Since then, my A1c has always been around 4.6-5.1, controlled by
metformin, exercise, and diet.

I gained back 35 lbs of fat over the next two years(to 2003) and was
able to drop only 10.  June of this year, I got serious again about
loosing last 25lbs of excess weight. Strong workouts at the gym
alternating days with long walk days, and 1400 kkals a day. Dropped
last 25 lbs from June to mid-September.

But about first of September, I caught something that resembled a low
fever flu in symptoms. Aches, pains, fatigue that would not go away.
I went to the lab for a new set of tests. My insulin and c-peptide
numbers had dropped from acceptable to less than 1/3 of the bottom
range of normal. All other tests were normal.

At this time, I began Amaryl at 1/2 mg a day, and Avandia(1st time
ever) at 2mg a day.  No more hypoglycemic episodes from the Amaryl.
Within a week I feel better than I have in years!  At this point, I'm
happy with my new meds.

Last Wednesday, I finally got to an endo here in Kiev. He suggests
dropping the Amaryl, saying it's "too harsh."  I do. Now I'm taking
Diabeton, beginning at 30 mg/day.

Complete meds currently taking:

Waking:    450 mg metformin, 2 mg Avandia, 30 mg Diabeton
Lunch:        450 mg metformin
Dinner:    450 mg metformin, 2 mg Avandia
Evening:    450 mg metformin, 5 mg Lipitor

Any comments on this new med regime?

Thanks,
Rich
from Kiev
Deb - 15 Oct 2005 12:06 GMT
I would ask about timed release metformin, assuming its available there.
That's what I take and it allows you to take it only once or twice a day and
not have to remember to take medicine so often. I for one get in a hurry and
forget mid day pills. I like Avandia for blood glucose control but it did
cause me to gain about 20 pounds. You'll have to stay vigilant to avoid
that. I did fine at first but then it started to creep up. Now I am fighting
to get it back down. I don't have any experiences with Diabeton so I will
leave this to others to comment on.

> There are some knowledgable people here. Can someone lend a few
> minutes?  Summary on top, unnessary rambling below.  ;-)
[quoted text clipped - 57 lines]
> Rich
> from Kiev
Dick Malchik - 15 Oct 2005 12:31 GMT
>I would ask about timed release metformin, assuming its available there.
>That's what I take and it allows you to take it only once or twice a day and
[quoted text clipped - 7 lines]
>> There are some knowledgable people here. Can someone lend a few
>> minutes?  Summary on top, unnessary rambling below.  ;-)

Deb,
Thank you!
Rich
Jenny - 15 Oct 2005 14:45 GMT
> But about first of September, I caught something that resembled a low
> fever flu in symptoms. Aches, pains, fatigue that would not go away.
> I went to the lab for a new set of tests. My insulin and c-peptide
> numbers had dropped from acceptable to less than 1/3 of the bottom
> range of normal. All other tests were normal.

If your c-peptide and insulin has dropped to 1/3 normal, you probably
should not be taking any sulfonylurea drug, including diabeton.  These
drugs force failing beta cells to produce insulin until they die.

It sounds like it might be a much better idea to use a basal insulin to
give your remaining beta cells some help and to prevent complete burn out.

Many doctors will not suggest insulin because they assume that their
patients will become too upset, but it is a much better treatment than
the sulfonylureas for people whose beta cells are failing. You sound
highly motivated so it shouldn't be a problem.
--Jenny

http://www.geocities.com/lottadata4u/  Type 2 Diabetes info
http://www.geocities.com/jenny_the_bean/  Low Carb info
Dick Malchik - 15 Oct 2005 21:22 GMT
>> But about first of September, I caught something that resembled a low
>> fever flu in symptoms. Aches, pains, fatigue that would not go away.
[quoted text clipped - 17 lines]
>http://www.geocities.com/lottadata4u/  Type 2 Diabetes info
>http://www.geocities.com/jenny_the_bean/  Low Carb info

You have some good advice, Jenny. The endo wants me to have new c-pep
test after 30 days using Diabeton. Maybe I should just ask to begin on
the lowest insulin dose Monday.

Thank you,
Rich
RK - 15 Oct 2005 15:10 GMT
| There are some knowledgable people here. Can someone lend a few
| minutes?  Summary on top, unnessary rambling below.  ;-)
[quoted text clipped - 4 lines]
| onset.  205-210 lbs, 5' 8" light frame.  Dropped almost 70lbs of ugly
| fat to 137-145 in 2001.

might have seemed like a few months, most likely was years prior
building up.

| Since then, my A1c has always been around 4.6-5.1, controlled by
| metformin, exercise, and diet.

congrats.

| I gained back 35 lbs of fat over the next two years(to 2003) and was
| able to drop only 10.

not good

| But about first of September, I caught something that resembled a low
| fever flu in symptoms. Aches, pains, fatigue that would not go away.

many folks get the flu.

| I went to the lab for a new set of tests. My insulin and c-peptide
| numbers had dropped from acceptable to less than 1/3 of the bottom
| range of normal. All other tests were normal.

dropped by 1/3? what were the results? what were they prior?
dropping a 1/3 could mean that the additional weight loss
prior helped bring them back into a more normal reading.

| Complete meds currently taking:
|
[quoted text clipped - 8 lines]
| Rich
| from Kiev

as a T2 you most definately need metformin for the IR.  T2's do
lose insulin production over the years.  What was your last a1c?

----
RK, T1/pumper/Animas IR1250
Dick Malchik - 15 Oct 2005 21:43 GMT
>| There are some knowledgable people here. Can someone lend a few
>| minutes?  Summary on top, unnessary rambling below.  ;-)
[quoted text clipped - 49 lines]
>----
>RK, T1/pumper/Animas IR1250

RK,
Thank you for the time, it's all very helpful.  Here are my recent
ins/cp numbers:

        4-05    9-4-05    9-27-05 Norm:
        ========================
A1c %        5.1    4.5    4.6    4.8-5.9           
Ins uIU/ml    20.9    3.41    3.45    8.9-28.4
C-pep ng/ml    0.92    --.-     <.5    1.1-5.0

The 1/3 comment was referring to insulin dropping from about 21 to
3.41, i.e., about 1/3 of the bottom of the normal range 8.9. Similar
CP from an acceptable .92 down to <.5, below the lower normal range of
1.1.

I've never had CP or insulin tests before, so I have no comparison
prior to April of this year. But something clearly changed from April
to September.

Thanks again,
Rich
oldal4865 - 16 Oct 2005 15:42 GMT
Dick Malchik wrote in message
<7bp2l1tgcsrl6gr78vllraqruigomoem17@4ax.com>...
. . .(snip). . .

>Thank you for the time, it's all very helpful.  Here are my recent
>ins/cp numbers:
[quoted text clipped - 16 lines]
>Thanks again,
>Rich

 Here's one tool to help you decipher your numbers.    It's not just
"fraction of the normal range" which should be considered.   Your fasting
insulin value represents a response to the amount of glucose in your blood.
A good analysis requires the application of some non-linear equations to the
balance between the two numbers.

Fortunately,  this analysis can be performed easily with the HOMA Calculator
which can be downloaded from the Oxford University site at

http://www.dtu.ox.ac.uk/index.html?maindoc=/riskengine/

You can plug in fasting insulin and fasting blood glucose and obtain an
estimate of current insulin resistance and current beta cell "capacity".
AFAIK,  this algorithm was used in the UKPDS and,  in another form,  used by
the pharma companies to evaluate new meds.

When I plug your 3.41 microUnits/ml into the algorithm,  then take a wild
guess at your fasting blood glucose,   (4.5 ???),   it returns the values:
% B = 68%,    I.R. index = 0.4

If my guess at your fasting blood glucose was close,  it suggests that you
have about 68% beta cell capacity when compared to some sort of "standard
human" at 100%,  and an (outstanding!) Insulin Resistance of 0.4 compared to
some sort of  "standard human" value of 1.0

Unfortunately,  I don't know how useful the algorithm is if you are under
the influence of a beta stimulator at the time of the test.   If you are a
glutton for punishment,  you can try wading through

  http://tinyurl.com/bfhal

for a better take on the situation.

Regards
 Old Al
Dick Malchik - 16 Oct 2005 21:09 GMT
>Dick Malchik wrote in message
><7bp2l1tgcsrl6gr78vllraqruigomoem17@4ax.com>...
[quoted text clipped - 56 lines]
>Regards
>  Old Al

Al,
THank you for the feedback. I was taking about .25mg Amaryl/day. Ten
days before the blood tests on the 27th, I stopped on Sept 17th. The
insulin 3.45 is almost identical to 3.41 from Sept 4, when I was not
taking any beta stimulators. I was fasting more than 12 hours prior to
the tests, during which time I did not take metformin or any other
drugs.

Your guess was close, my fasting glucose was 4.8. These are the
numbers using the "Copy" tab on the HOMA2.2 calculator.

Plasma glucose    4.8    mmol/l
Specific insulin    3.45    µU/ml
HOMA %B    66.0
HOMA %S    195.3
HOMA IR    0.5

Chol TTL  5.6, HDL 1.7, Tri .6 (all mmol/l)

Thank you again,
Rich
oldal4865 - 17 Oct 2005 14:00 GMT
Dick Malchik wrote in message
<2r95l1tg26c86hil3381c9u1g7gh7i683a@4ax.com>...

>Al,
>THank you for the feedback. I was taking about .25mg Amaryl/day. Ten
[quoted text clipped - 17 lines]
>Thank you again,
>Rich

   Really spectacular Insulin Resistance.   Looks like a set of values for
somebody planning on "living forever".

The T2 bug-a-boo:   triglycerides/HDL:   Below 1.3 as a target but otherwise
as low as possible.    Your 0.35 is just plain spectacular.

The "male" bug-a-boo:  Total/HDL:   Below 4 as target but below 3 is better:
Your 3.3 is getting there.

Some general remarks on attacking your total cholesterol:

I'm not allowed to take statins so I have to do it the hard way.

After reading:

"50 Ways to Lower Your Cholesterol".   McGowan, Mary P., M.D.

My anti-cholesterol regime is:

 Freshly ground Flax seed every morning
 Oatmeal every morning
  Fish Oil,  3000 mg/day
  Policosanol
 Guggul
 Garlic
 Niacin.   1000 mg/day
 Benecol sterol ester margarine
 Olive oil as the fat of choice in cooking
 Pantethine (vitamin with unusual anti-cholesterol effects)
 Pysllium  (when I remember)

Soy flour is supposed to help but I can't find a good way of adding it to my
diet.

Works very well for me.     I suspect it may be difficult to do stuff like
this in Kiev but it's not too burdensome in the U.S.    (Note: the niacin is
aimed at triglycerides but yours are already spectacular.)

Regards
 Old Al
Jenny - 17 Oct 2005 14:24 GMT
> Dick Malchik wrote in message
> <2r95l1tg26c86hil3381c9u1g7gh7i683a@4ax.com>...
[quoted text clipped - 50 lines]
> Soy flour is supposed to help but I can't find a good way of adding it to my
> diet.

Al,

Since you are LADA, doesn't that make you at higher risk for autoimmune
thyroid problems?

If so, you should be avoiding soy products. Mainstream thinking is that
they are very hard on compromised thyroids.  The rest of your protocol
looks great. Glad to hear it is working for you!

--Jenny

http://www.geocities.com/lottadata4u/  Type 2 Diabetes info
http://www.geocities.com/jenny_the_bean/  Low Carb info
oldal4865 - 18 Oct 2005 13:50 GMT
Jenny wrote in message ...
. . .(snip). . .

>Al,
>
[quoted text clipped - 9 lines]
>http://www.geocities.com/lottadata4u/  Type 2 Diabetes info
>http://www.geocities.com/jenny_the_bean/  Low Carb info

 Now that's an interesting thought.

 FWIW,   my immune system is still giving me problems.    I have suffered
bone loss at my artificial hip because "my body's reaction to particles shed
by the artificial hip resulted in an autoimmune attack on the bone".    What
this means is that on Dec 8 I go back into surgery and have them remove the
old socket,   reshape the damaged bone area,  and install a bigger socket.
Whoopee!   Six years service from a 15+ year model artificial hip.

Regards
 Old Al
None Given - 18 Oct 2005 18:34 GMT
>   FWIW,   my immune system is still giving me problems.    I have suffered
> bone loss at my artificial hip because "my body's reaction to particles shed
> by the artificial hip resulted in an autoimmune attack on the bone".    What
> this means is that on Dec 8 I go back into surgery and have them remove the
> old socket,   reshape the damaged bone area,  and install a bigger socket.
> Whoopee!   Six years service from a 15+ year model artificial hip.

Does that mean the work is covered under warranty?

Signature

No Husband Has Ever Been Shot While Doing The Dishes

Jenny - 18 Oct 2005 19:33 GMT
> Jenny wrote in message ...
> .. . .(snip). . .
[quoted text clipped - 24 lines]
> Regards
>   Old Al

Sorry to hear you are having to have more surgery on your hip. I hope
all goes well and you recover swiftly!

Signature

--Jenny

http://www.geocities.com/lottadata4u/  Type 2 Diabetes info
http://www.geocities.com/jenny_the_bean/  Low Carb info

Tiger Lily - 18 Oct 2005 20:07 GMT
dang Al.......... sorry to hear about your hip

hope the surgery and recovery goes well and
quickly

those PTherapists really like to put us don't
they?

kate
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I have no medical qualifications beyond my own
experience.
Choose your advisers carefully, because experience
can be
an expensive teacher.

> Jenny wrote in message ...
> . . .(snip). . .
[quoted text clipped - 24 lines]
> Regards
>   Old Al
Dick Malchik - 17 Oct 2005 16:11 GMT
>Dick Malchik wrote in message
><2r95l1tg26c86hil3381c9u1g7gh7i683a@4ax.com>...
>>
>>Al,
>>THank you for the feedback. I was taking about .25mg Amaryl/day. Ten

>>Chol TTL  5.6, HDL 1.7, Tri .6 (all mmol/l)
>>
[quoted text clipped - 41 lines]
>Regards
>  Old Al

That's great work on your cholesterol control without statins. My chol
numbers were much better when I took 10mg Lipitor a day, about 150-175
ttl with a TTL/HDL ratio of about 2.5. The numbers I posted were
without statins. I'm trying 5 mg/day now, and will have another lipid
panel in a month.

I like oatmeal, and could drop my TTL chol about 10-15 pts by eating a
serving every morning. But it was difficult to control my BG with that
much carb at once. You mentioned you have great triglyceride numbers
now. How much oatmeal do you eat, and what are the other sources of
your carbs and amounts?

This metformin, diabeton, rosiglitazone combination is giving me
awesome BG control. My tests, and I'm doing many, are all between
4.0-6.5.  This even after I've eaten a "normal size test" serving of
foods I previously had to have 1/4 serving or less.

My endo did not answer his phone today. Tomorrow I'll ask about
beginning a minimum program of insulin.

Thank you again,
Rich
None Given - 17 Oct 2005 16:49 GMT
> I like oatmeal, and could drop my TTL chol about 10-15 pts by eating a
> serving every morning. But it was difficult to control my BG with that
> much carb at once. You mentioned you have great triglyceride numbers
> now. How much oatmeal do you eat, and what are the other sources of
> your carbs and amounts?

Steel cut oats may have less of an effect on BG, add oat bran, it is
supposed to be even better than oatmeal for lowering cholesterol.  Maybe
eating it in the evening instead of the morning would work better.

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No Husband Has Ever Been Shot While Doing The Dishes

Nicky - 17 Oct 2005 20:50 GMT
> Steel cut oats may have less of an effect on BG, add oat bran, it is
> supposed to be even better than oatmeal for lowering cholesterol.  Maybe
> eating it in the evening instead of the morning would work better.

Can you make a porridge out of oat bran? Oats themselves send my bg
stratospheric, but bran is fine. If you can get the same benefits...

Nicky.

Signature

A1c 10.5/5.6/<6  T2 DX 05/2004
1g Metformin, 100ug Thyroxine
95/74/72Kg

None Given - 17 Oct 2005 22:26 GMT
> > Steel cut oats may have less of an effect on BG, add oat bran, it is
> > supposed to be even better than oatmeal for lowering cholesterol.  Maybe
> > eating it in the evening instead of the morning would work better.
>
> Can you make a porridge out of oat bran? Oats themselves send my bg
> stratospheric, but bran is fine. If you can get the same benefits...

I'm sure you could, if you like it that way.  I think I saw it in a cereal
section somewhere, the only ingredient listed was oat bran.  I'm not sure if
the taste would be comparable.

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No Husband Has Ever Been Shot While Doing The Dishes

Nicky - 17 Oct 2005 23:04 GMT
>> > Steel cut oats may have less of an effect on BG, add oat bran, it is
>> > supposed to be even better than oatmeal for lowering cholesterol.
[quoted text clipped - 8 lines]
> if
> the taste would be comparable.

Hmmm. I think I'll add it in to my flaxseed porridge mix next time I make
some.

Nicky.

Signature

A1c 10.5/5.6/<6  T2 DX 05/2004
1g Metformin, 100ug Thyroxine
95/74/72Kg

oldal4865 - 18 Oct 2005 13:45 GMT
Dick Malchik wrote in message
<7je7l1dmrps21r3loo708a53pk6jl2q836@4ax.com>...
. . . .(snip). . ..

>I like oatmeal, and could drop my TTL chol about 10-15 pts by eating a
>serving every morning. But it was difficult to control my BG with that
[quoted text clipped - 6 lines]
>Thank you again,
>Rich

I eat a bit less than 1/2 cup (as uncooked) mixed with freshly ground flax
seed from 1/4 cup of whole seed.    It's a hi-carb/fast-carb breakfast but I
am T1-on-insulin so it's merely a question of proper injection timing,
injection amount and exercise opportunity.   Tricky (actually a PITA) but
very possible.      It's strictly a heart-smart option for me.     I take my
oatmeal,  my measuring cup and my bowl with me when I travel.

Since I am T1-on-insulin,   my carb input is meaningless to a T2.    I use
DAFNE  (Dose Adjusted For Normal Eating) in a 200-250 gram carb/day regime
and basically eat anything I want within reason   (e.g.  my bG often drops
instead of spiking after a pasta meal).

On insulin for a T2 early in the Progression:

There are a variety of clinical studies which suggest but do not prove that:

     a.  The beta death mechanism (apoptosis) which is the proximate cause
of T2 is more or less proportional to the rate of insulin production

     b.  There is some sort of repair mechanism in T2 which acts to replace
dead beta cells.  In most T2,  the death rate overwhelms the replacement
rate.

     c.   However, taking the load off the beta cells via insulin
injection.and/or massive reductions in Insulin Resistance seems to allow a
rejuvenation or net gain in insulin production capacity.     That is a very
good thing for a T2.

There is a trap however.    If high Insulin Resistance is present and you do
not manage to knock it down,   the extra circulating insulin potential from
insulin injection can encourage damage to arteries.   Therefore,   attacks
on I.R. and circulating insulin levels are the #1 priorities  (anti-heart
attack) for T2.   That means fat loss,  muscle gain,  daily exercise and low
carb.

In your case,  note that many T2 exhibit  I above 2.0 (some above 4 !) in
the HOMA test.   Your 0.4 is simply spectacular.

Some cites:

1.  Take the test at

http://www.diabetesincontrol.com/modules.php?name=News&file=article&sid=2867
,    pick answer "8",   read the explanation which represents clinical proof
that insulin injections protect beta cells

2.  Metformin (and TZD also) have a beneficial  effect on apoptosis

http://jcem.endojournals.org/cgi/content/abstract/89/11/5535

3.  Finally,  Uncle Enrico's approach to early insulin

"Uncle Enrico
Sunday, June 05, 2005 12:45 AM
alt.support.diabetes

I was on your same dosage of Glipizide for several years and had two or
three hypos a week, particularly with exercise. I always had to carry
glucose tabs. I gained weight with Glipizide and often had ruined
exercise outings because of the hypos. The effect of Glipizide seemed to
be a little too unpredictable, no matter how closely I monitored things.

Then, a well-respected endo visited my diabetes support group and told
me and others that Glipizide and other sulfonylureas had these
characteristics--weight gain and hypos. She said she preferred beginning
with insulin sensitizers like Metformin/Glucophage, and then only going
to insulin pushers like Glipizide if diet, exercise and Metformin didn't
work.

I soon began taking Metformin,  went on a strict slow carb/low carb
diet, along with 1 to 2 hours of daily exercise, gradually reduced my
Glipizide to a very small amount, 1.25 mg a day, as I lost 45 pounds in
10 months. Despite the small amount of Glipizide, I still got hypos.

I did some research into the benefits of "early insulin therapy,"
discussed it with my doctor, and am now taking a small dose of insulin
in the morning only, to deal with my dawn phenomenon. I've eliminated
the Glipizide and am keeping my weight down. My last A1C before going on
the insulin, and while still taking 1.25 mg. of Glipizide was a 5.3. The
insulin has improved my morning and afternoon numbers, so I'm expecting
a better A1C on the next test.  I have had absolutely no hypos with the
small dose of insulin I take each morning.

All the professionals I've talked to, my doctor, 1 endo and 2 diabetes
educators, believe that I'm on the right path. A Dr. Richard K.
Bernstein, M.D. has advocated this approach for many years. He has a
book  titled "Diabetes Solution" that I've closely read and refer to
often. Bernstein advocates small doses of insulin and a strict low
carb/slow carb diet for both his Type I's and II's.

There is ample research to support the value of early insulin therapy.
Leading endocrinologists support this treatment. My goal is to preserve
my ability to produce insulin rather than burning out what I've got left
with sulfonylureas. I'm not suggesting anyone do this. I'm just telling
you what has worked for me.

Frankly, I don't think that early insulin therapy would have been right
for me if I were still seriously overweight. More insulin could make
weight loss harder and increase my problem with insulin resistance. I
feel comfortable with this program because I have reached a normal
weight and continue to maintain it.

By the way, modern syringes are virtually painless. There is an
emotional barrier that causes diabetics to resist insulin treatment that
I believe is unjustified given research data showing the efficacy of
"early" rather than "last resort" insulin therapy.

Type II
Dx'd 5/98
Insulin and Metformin
Diet: I prepare all my own food: slow carb/low carb. Lean protein and
lots of slow carb vegetables, nuts, olive oil.
Recently added Blueberries to the diet.
Exercise: daily walking and or biking--one to two hours.
Height: 5' 7"  Weight: 158 pounds, down from 203 ten months ago.
A1C 5.3"

Regards
 Old Al
Dick Malchik - 18 Oct 2005 17:09 GMT
>Dick Malchik wrote in message
><7je7l1dmrps21r3loo708a53pk6jl2q836@4ax.com>...
[quoted text clipped - 130 lines]
>Regards
>  Old Al

You're convincing me. I'm still trying to reach my endo. On my own, I
had pituitary, adrenal, and thyroid tests done. This is in addition to
what the endo requested, only c-peptide.

Best wishes on your hip work.

Rich
oldal4865 - 15 Oct 2005 15:42 GMT
Dick Malchik wrote in message ...
>There are some knowledgable people here. Can someone lend a few
>minutes?  Summary on top, unnessary rambling below.  ;-)
[quoted text clipped - 57 lines]
>Rich
>from Kiev

    The meds you are taking can be described in general terms as:

 1.  Anti-Insulin Resistance meds:   Avandia and metformin

 2.  A beta cell stimulator:  Diabeton  (IIRC, Glyburide in the U.S.)

 3.  An anti-cholesterol statin:  Lipitor

Alternately,  your total therapy might be re-classified as:

 1.  Anti-heart attack therapy:

          i.  Losing fat,  gaining muscle
         ii.  Daily exercise
        iii.  Restricted carb diet
         iv. Significant metformin  (note;  you are not using  "maximum"
metformin)
         v.  Avandia
        vi.  Lipitor

 2.  "Protect your beta cells" therapy

     i.   (i - v) above
    ii.   Avoid beta cell stimulators. . .oops,  you're not doing that

3.  Blood sugar control therapy

       i.   (i - v) above
      ii.   Diabeton beta cell stimulator

BTW:   Don't fixate on blood sugar control.     Anti-heart attack is more
important.    One can argue that "Protecting Beta Cells" is also more
important.

In general,   the most modern recommended therapies  for T2 diabetes seem to
be:

a.  Convince the patient to attack the disease by losing weight,  exercising
daily  or as often as possible,  and choosing a low carb diet.

b..  Use meds to attack the high Insulin Resistance exhibited by the
majority of T2.   The high Insulin Resistance is a key factor in the high
heart attack risk characteristic of T2.    It also is thought to encourage
the premature death of beta cells which is the proximate cause of T2.
Metformin is the first med of choice in attacking high I.R.      Avandia or
Actos   (never both)  is the second,  primarily because both encourage fat
gain and water retention.      Metformin attacks I.R. via a very different
mechanism than the TZD (Actos/Avandia) so you can use both simultaneously.

The U.S. PDR asserts that the  clinically effective dose of metformin is
about 1500 mg/day and the maximum dose allowed is about 2550 mg/day.

c.   If the low carb diet,  exercise,  weight loss and anti-Insulin
Resistance med therapies don't succeed in reducing blood sugars,  add a beta
stimulator of some sort.   Glyburide is popular in the U.S.

d.  Add insulin injections when appropriate.

T2 diabetes is a "Progressive" disease in that as time passes,  it usually
becomes more and more difficult to control blood sugar.   The progression is
usually caused by the progressive death of beta cells.   When enough cells
have died,   insulin injections must be used.

Since the ultimate result of using beta stimulators (Amaryl,  Diabeton) is
thought by many to be an increase in the death rate of beta cells,   many
docs think that early supplemental insulin injections are a better choice
than beta stimulators.    This is a controversial and difficult subject
since insulin injections are thought to increase the risk of hypoglycemia
more so than beta stimulators.  Thus many docs prefer to risk early beta
cell death in preference to risk of hypo.

Of course,  when enough beta cells are dead,  the T2 needs insulin anyway so
the risk of hypo is merely delayed.

Your comment ". . . .My insulin and c-peptide numbers had dropped from
acceptable to less than 1/3 of the bottom range of normal. . ." suggests
that you have a lot of dead beta cells.

My very controversial opinion  (engineer not a medical person). . .Those
beta stimulators (Amaryl,  Diabeton) haven't been doing you any favors at
all.      You might consider ***supplemental** insulin in place of the beta
stimulators.   That might slow the Progression,  i.e.  delay the time at
which you too become totally insulin dependent.   Speaking as a person who
is totally insulin dependent,  "supplemental" is a better place to be than
"totally dependent"

You never did mention "low carb".    Note that T2 must strive  (strive =
work like H*ll)  to keep their triglycerides down.   High carb + Diabeton is
a recipe for high triglycerides.    Low carb fights high triglycerides.

A very good "Human-Being-Anti-Heart-Attack-Strategy"  is keep your
triglycerides/HDL ratio below 1.3  (when measured in mmol/L)

FWIW,   my ratio is about 0.5 but it took years of fiddling to get there.

Regards
 Old Al
Dick Malchik - 15 Oct 2005 23:05 GMT
>Dick Malchik wrote in message ...
>>There are some knowledgable people here. Can someone lend a few
[quoted text clipped - 156 lines]
>Regards
>  Old Al

Ol' Al,

Great analysis, thanks. Tell me, what is a good target for low carb?
Already, I eat about 40% of my cals this way.  Almost all carbs are
from beans(100-150g/day) garden vegetables(ex: broccoli, cabbage
cauliflower, green beans, tomatoes, cukes, so on) and dark breads
labeled less than 40g/100g carb. I know my triglycerides are very low.

I switched to the Diabeton only two days ago.  I've been feeling
rather lethargic following another bout of the "??flu??" and not
eating much Wed and Thurs.

I don't know if the muscle weakness is from the new meds or the
passing illness, or a combination. I'm told the Diabeton should kick
in in a week. If not, I should double the dose from 30mg/day to
60mg/day.

Your advice on trying insulin sounds good. I think I should try to
convince the endo to start me on the smallest therapeutic dose as soon
as possible. And not increase the diabeton at all.

Thank your for sharing your experience and analytic skills,
Rich
Grandpa Chuck - 16 Oct 2005 00:12 GMT
<snip>

Rich do you know how to snip?

I'll be the first to admit that I forget to do it way too much of the
time. Maybe you can remind me once in awhile when I have close the 190
lines you had in this post and I will give you a "psst" when you do it
too? Deal?

>Thank your for sharing your experience and analytic skills,
>Rich

--

Grandpa Chuck
-ô¿ô-
 ~

A candle loses nothing by lighting another candle.

Love is giving all with no conditions.
Love is expecting nothing in return.


William Pershing - 15 Oct 2005 17:29 GMT
Sounds like you have a good start....perhaps when you get to the states
you can look at Actos as an alternative?~Bill

> There are some knowledgable people here. Can someone lend a few
> minutes?  Summary on top, unnessary rambling below.  ;-)
[quoted text clipped - 57 lines]
> Rich
> from Kiev
 
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