Diabetes Medicine while cirrhosis but compensated

[somuchmore2]

Any suggestions on better or not so better meds to treat beginning stage of type 2 diabetes?

There appears to be many. All have different side effects, etc...

I think my exercise and diet plan has held me off meds so far, but later showing higher glucose levels AM (>150) etc...

[GoofyDad]

" I walk 25 miles a week "

Why not move the refrigerator closer to the TV? Or make the teenager earn her keep?

[somuchmore2]

Thanks to all for some much good information.

[mikesimon]

Dapsone is also used for MRSA and leprosy Bill.
I take Dapsone as a prophylaxis for Pneumocystis carinii pneumonia which is thought to be a risk to liver transplant patients. Bactrim can also be used but I had a mild allergic reaction to Bactrim early post transplant so I was switched to Dapsone. My understanding is that many, if not most, transplant centers discontinue these drugs months after transplant. Mine believes in prophylaxis for life but I am seriously considering discontinuing the Dapsone. I am over 10 years out and never had Epstein Barr or Cytomegalovirus which are thought to make Pneumocystis infection more likely.
I never did have a weigh issue but I have gained some weight in the last 18 months and could stand to lose 15 pounds so maybe insulin has stimulated a weight gain. There's always something to worry about - isn't there Bill?

Be well,
Mike

[HectorSF]

A comment on compensated and decompensated cirrhosis.

"Oh! I have had a esophageal bleed with grade III varices. Current med includes nadolol" and omeprazole.....
Grade III varices are large varices that measure 3-4 mm in diameter, are straight or tortuous, and sparse in number around the circumference of the esophagus at the level where they are located. Esophageal varices develop when normal blood flow to your liver is slowed due to scarring of the liver. The blood then backs up into nearby smaller blood vessels, such as those in your esophagus, causing the vessels to swell. Sometimes, esophageal varices can rupture, causing life-threatening bleeding.

Nadolol is given to reduce portal hypertension . A symptoms of decompensated cirrhosis.

Symptoms and Complications of Decompensated Cirrhosis -

Patients with decompensated cirrhosis develop a variety of symptoms such as fatigue, exhaustion, loss of appetite, nausea, jaundice, weight loss, stomach pain, ,impotence, bruising and bleeding, and other potentially life threatening symptoms. Complications will also develop because the liver is unable to perform many functions. Complications can include:
• A combination of factors such as portal hypertension, low albumin levels and kidney dysfunction produce an accumulation of fluid in the body. Ascites is the accumulation of fluid in the abdominal cavity. Edema is the accumulation of fluid in the extremities, especially the feet and legs.
• Bleeding problems (coagulopathy) develop as the liver is unable to produce clotting factors. In addition platelet (for blood clotting) count drops because of an enlarged
spleen.
• As liver disease progresses there is bone mass and density loss.
• The spleen stores red and white blood cells and platelets. An enlarged spleen develops due to blood being forced into it when portal hypertension develops. An enlarged spleen loses its ability to store red and white blood cells, and platelets.
• Hardening of the Liver due to dying liver cells can be felt on examination.
• A damaged liver is unable to regulate the production and breakdown of some female and male hormones. In women this can cause menstrual irregularities, and in men, gynecomastia (breast enlargement).
• Impaired Mental Status is due to many factors. Toxic substances that are usually filtered by the liver reach the brain. Symptoms of encephalopathy include personality changes, changes in sleep patterns, sluggish
movements, drowsiness, confusion, stupor, and coma.
• Itching (pruritus) can develop that can be debilitating. The cause of pruritus is believed to be caused by impairment or failure of bile flow complicated by jaundice.
• Kidney function deteriorates in someone with decompensated cirrhosis, contributing to fluid retention (ascites, edema) and various kidney disorders.
• People with hepatitis C who develop cirrhosis are at risk for liver cancer.
• Muscle wasting can result from the liver’s inability to metabolize proteins, which can make a person with cirrhosis more prone to bone fractures.
• Scar tissue in the liver restricts the flow of blood and leads to portal hypertension resulting in complications
such as ascites, spontaneous bacterial peritonitis, varices and other potentially life-threatening complications.
• Spontaneous Bacterial Peritonitis is a condition caused when the body’s natural bacteria enters the ascites fluid causing severe infection.
• The veins in the stomach, esophagus and rectum become so stretched and dilated (due to portal hypertension) that a condition called varices develops which can lead to internal bleeding.
When the liver completely breaks down and is unable to perform its job, it is called end-stage liver disease (ESLD).
The goal at this stage is to try to manage complications due to a deteriorating liver.

Unfortunately, antiviral treatment is generally not recommended for people with
decompensated cirrhosis because HCV therapy can accelerate the decompensation process. If people are treated with HCV medications at this stage it is usually
in the setting of a transplant center that can carefully monitor people during therapy. Currently, the only potentially effective treatment for end-stage liver disease is liver transplantation.

Hectorsf

[desrt]

Interesting thread.
I lost 40 lb. after I started taking 500 mg of the extended release Metformin twice a day. When I got down to 190 (6'2") doc let me cut back to one a day and my fasting #s stayed the same (around 100 give or take).

[Bill1954]

Mike, you don’t have an issue with weight, if I recall; I imagine insulin would likely work pretty well for you. My doctor was concerned that it might promote weight gain; and besides, during HCV treatment it really stopped working for me.

My resistance became so high towards the end of treatment I was using all three oral drugs along with 115 units of Lantus insulin, and was regularly getting fingerstick results above 200, and A1c results of >8.5. A few months after I completed treatment, my insulin needs began tailing off, and I eventually stopped using it.

I bet you’d do well with metformin; it’s not noted for hypoglycemic episodes when used by itself, and other than some initial and rather minor GI issues it’s generally well tolerated.  If your resistance isn’t very high, and it sounds like it’s not, you might get by with 500 or 1000 mg/day.

I think it’s been pretty well vetted over the years; I don’t think there have been any strange stuff like cardiovascular toxicity as with some of the others like Avandia.

Dapsone sounds like it’s used primarily for skin issues; was this part of transplant medicine?  It’s also apparently used for brown recluse spider bites :o)?

Good to see you posting, Michael—

Bill

[mikesimon]

I never tried oral meds for DM. I became diabetic after transplant and at that time I had a pretty vigorous regime - med wise. So, after research and discussion I decided insulin was the way for me. I asked several hepatologists which was the most benign drug and they agreed that exogenous insulin was probably the best in that respect - it didn't stimulate the pancreas of inhibit the liver. At that time I didn't want any more drugs impacting any organs. My A1C is affected by a drug I take - Dapsone - which causes low level hemolytic anemia. It was 3.8 a couple of weeks ago and though it's good I know it isn't that low. I stopped the Dapsone a while ago for about 4 months and tested - A1C = 5.5 - which I believe is accurate. I'm going to stop that drug for good soon.
I have read a lot of good things about Metformin and I believe I may start taking that drug. I don't take much insulin - if I eat really right I need almost none. But, it is a cheater drug and it's easy to abuse diet and maintain normal range glucose levels - just dial up the pen.

Mike

[FlGuy]

I just coomented to my wife this past weekend that it seems that Amaryl and Metformin are cheaper than a similar amount of candy. But, not as satisfying as Milk Duds.  Didn't realize you kicked the needle habit.  Good for you.

[Bill1954]

I’ve been using metformin, glipizide and Actos concurrently now for a few years, and at this point, between meds, diet and exercise I’m staying under tight control. My A1C has been under 6.0 consistently; for the past year and a half, anyway.  

During treatment, my blood sugar became *very* problematic, and I ended up adding Lantus insulin on top of the oral meds. I no longer require insulin; it tends to promote weight gain in those that are predisposed to that, from what I understand.

I think metformin actually promotes weight loss; it seems to be the drug of choice initially for DM II; and it’s very affordable on top of everything else. I’d take a good look at it; like I say; it’s been around for a while now.

Good luck with everything,

Bill

[FlGuy]

Amaryl and Metformin are about the limit of my expereince.  I was on insulin for a while but goal was to get off all meds with behavior changes.  As for the weight, I have the opposite problem.  My walking burns the weight but my avoidance of a lot of foods keeps me from keeping up.  I'm in the low end of BMI and I'm still trying to master the eating side of things which I haven't completely figured out yet.  I'm looking to replace pound cake and YooHoo and meatloaf and mashed potatoes.  Until then I have a food gap.

[somuchmore2]

Thanks.

And, good luck to you too.  

[can-do-man]

Also being cirrhotic my hepo put me on actos, didn't notice any sides from them..... Good luck

cando

[somuchmore2]

Thank you.

5.7! that is really good. My exercise is pretty much in place and constant as I am determined to be in the best fit as possible while haveing Hep C and Diabetes.  Reckon the multiple meds at same time is a little perplexing to me. Never being on any for the diabetes is a little over  my head. In just a couple of months I've gained 8/9 lbs on Amaryl which is not what I want to do.

Are any of the other meds better for weight control than the other?

[FlGuy]

I'm not sure but your liver condition might be a complicating factor.  I take both Amaryl , also 1 mg, plus 2000 mg metformin and I finally have it under control.  I walk 25 miles a week and watching diet fairly closely.  I think you have some room in the dosing of the amaryl since I think 1 mg is just about the minimum dose.  Although many people use insulin (Bill is one) I'm trying to avoid it. So, I walk and walk some more.  Blood sugar is better (5.7),  without affecting ast/alt but my feet, knees and back are screaming at me. If you're not taking metformin yet, you might talk with the doc.  I haven't noticed sx from either.

[somuchmore2]

Thanks.

HCV is >37 years and I've been treated 2x first in 1998 with inter/riba and then 2002 peg-inter/riba. Waiting for the next gen of stuff like vertex med or transplant in future. Genotype 1A and I suspect cirrhosis is stage iv, but still compensated with good numbers overall. Latest A1C is 7.4. I'd managed to keep it down to lower 6 by exercise and diet, but lately it has climbed.

First, med they gave me was Amaryl and that is really taken me too low on just 1mg dosage.

What about Juniva? Any opinion on that along with the liver.....condition.

Oh! I have had a esophageal bleed with grade III varices. Current med  includes nadolol and omeprazole.....

[Bill1954]

Metformin has been around for a long time, and is pretty effective at decreasing insulin resistance. It might increase liver enzymes a touch, but it’s usually a pretty good trade off. If you initiate metformin, you might get some mild to moderate GI issues; but these generally resolve after several weeks.

Keep up with diet and exercise though; it really is an important component of DM II management, like it or not. What sort of A1c numbers are you getting?

Are you considering HCV therapy? I’m assuming your cirrhosis is due to HCV?

Have you tried any other DM meds yet, including insulin?

Bill