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Insulin glucose rations and opinionsFrom: Mark Jutras (mjutras@gate.net)Wed Jan 12 08:00:21 2000
This area has a lot of opinion so I will give you my opinions. Women are much more likely to have an abnormal 2 hour glucose than fasting glucose. When I screen I no longer use just fasting values because of the confusion. I do a 2 hour GTT with both glucose and insulin measured at fasting, 30 min, 1 hour, and 2 hour. The fasting ratio should be greater than 4.5. The 2 hour ratio should be greater than 1. You should also see an early peak in insulin with the value clearly falling by 2 hours and usually by one hour. Another unclear question is what is a normal insulin level. Clearly a fasting insulin level over 20 is high. What about 15, or 12, or 10? Not clear to me. What about peak insulin? Over 100 micro units/ml is probably abnormal. I also look at HgA1C. We have had a few with normal glucose levels but with HgA1C over 6.0 which my perinatologist believes is the point were the rate of birth defects begins to rise. Probably the reason that obese women have a higher rate of neurologic birth defects despite use of folic acid. Good resident/fellow study. I look at lipid panels. Almost all of these women have high LDL and/or VLDL. Most have elevated total cholesterol and some have elevated triglycerides. Just had one with cholesterol of 700 and TG over 3300 (nml <200 for both). This frequently is the motivator that gets them on the diet and exercise. I look at testosterone and androstenedione. A surprising number have only high normal T but have marked elevation on A. DHEA-S can also be elevated and respond to treatment. I tried looking at PAI-1 in two different reference labs but have concluded this assay is not ready for prime time. Elevation is strongly elevated with premature coronary disease and pregnancy wastage. For treatment I start with metformin 500 TID in all. Tried 500 and 1000 BID and 850 TID but have decided this is the most predictable. Was told by the drug rep that they do not believe doses over 2000 mg a day benefits the patient even though they have approval for use up to 2500. If they do not respond to this dose with correction of the laboratory abnormalities I add Avandia 4 mg BID. I have seen some dramatic effects with the combination. These drugs are purely additive in level of improvement seen which is unusual in medical therapy. I believe each improve diabetic control by about 20% and together they produce a 40% improvement ( I pulled those numbers from the air but I believe they are close to correct). Diet is extremely important. I give prescriptions for dietary consult which is universally denied by the insurance companies. The required diet is high protein/low carbohydrate. Some of the major weight loss clinics have specific diabetic weight loss programs or high protein/low carb programs. There is also Adkins books and the Carbohydrate Addict series. Diet is EXTREMELY IMPORTANT. If all they want is a pill they are unlikely to respond well. For billing codes I use PCOD (256.8) and/or hyperinsulinemia (251.1) or diabetes (if they meet the strict diagnosis - you don't want to use that label if you can avoid it). All the companies have covered all aspects of diagnosis, treatment, and follow-up except for the dietitian. If they have the disease I tell them to have brothers, sisters, and parents checked also. What about patients with normal labs but ultrasound diagnosis of PCOS. It appears that some of them will respond to the drugs also so it could be worth a trial. Europeans use ultrasound as a major part of their diagnostic criteria for PCOS and they are probably correct in doing this. If it looks like a duck and it fails to ovulate like a duck it is probably a duck. I continue the drugs till pregnancy is confirmed. This may change since there are unpublished reports of lower miscarriage rates if it is continued. There are at least two research studies looking at metformin in pregnancy with good results and no reported negatives. All of these drugs are class B last I looked. Life time treatment? Makes theoretical sense if you believe that the pancreas wears out from over load. Most people do believe this. Look at women with gestation diabetes. The more pregnancies they have the earlier and more severe the diabetes they develop. My opinions. Looking forward to other's opinions.
-- Mark Jutras, MD Orlando mjutras@gate.net
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