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A. Schuyler, NP
A. Schuyler, NP, Nurse Practitioner
Category: Health
Satisfied Customers: 16292
Experience:  Board Certified NP, MS, RN. 25 years private practice & hospitalist
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Dr Chauhan, I am writing you about oral diabetic meds. If

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Dr Chauhan, I am writing you about oral diabetic meds. If you feel another doctor online may be more qualified on the topic, please give me the professional courtesy to "punt" to that doctor. For a payment ,I will expect an answer that a good endocrinologist would readily consider because of excellent,defenseable clinical and pharmaceutical rationales. I had my first visit to an endocrinologist in Jan 09. He took me off Novolog(only started it along with Lantus in 8/07). He added 2000 mg of metformin in place of the Novolog. It has worked well so far. I am also on 30mg actos and 8mg glimepiride and have been on oral meds for a total of 18 yrs. He left me on the Lantus(30 units nightly). I like no premeal shots and my A1c's have been good-6.5 in 10/08, and 5.7 in Jan. 09. I have learned that it is deemed best to use the diabetic oral meds from varied classifications of the 6 that are available.
The issue is that I go from private health insurance to a Medicare drug plan on 5/1/09. The cost "killer" is Actos. My copays and premiums combined will jump about $2000 a year. This is not affordable. I have searched the available plans for months to find the most cost effective and I do not qualify for any drug assistance.
Both my internal medicine doctor and the endo have told me to go back to Novolog if I want to discontinue Actos. Well, insulin is also pretty expensive too and no generics for it either.
I need to know which generic oral med(s) to ask them to at least try out. As I said at the beginning , quality clinical/ pharmaceutical rational is very important to use with the endo. Finally, I think it is very important that I can walk into my next appt on 4/20 and show him a doctor's feedback who has successfully had patients switch from actos to XXXXX generic and maintained their glycemic control.
I have had close to 25,000 in health care out of pockets in the last 2 years. I obviously will be making payments on these for a few more years. A triple hernia surgery(3 are not common at all), extensive gum surgery as a result of some out of control diabetes, 5 dental crown replacements, one root canal, and surgery for bladder cancer. BCG treatments still ongoing for that. It was caught before invading the bladder lining,thank God. All these things occured from 5/07 to 1/09.
I trust you realize that I know your expertise is likely worth far more than I can afford but I would really appreciate your time and expertise.

I will refer you to an expert who may be able to help you
Customer: replied 8 years ago.
It appears you are asking me to pay $12 for you to refer me to someone else. I will gladly pay the person who gives me an acceptable answer about a viable substitute for actos with sound support that an endocrinologist would likely buy into. When I said that if whoever picks up my question feels it more appropriate to forward it to another doctor in the group to please do that. I certainly did not expect to pay someone to "punt" to someone else.
i did not ask you or was I expecting you to pay me anything. you accept once. i was trying to do you a favor.
Customer: replied 8 years ago.
Thanks for clarifying the situation. I am not very familiar with the protocals here. I did not want to click on accept and for that to mean I needed to pay you for a referral. Since you didnt say one way or the other about a payment, I wanted to be very cautious about this. Since my initial email stated to refer if you felt that was appropriate, I was thrown for a loop with you coming back and asking if I wanted you to proceed with a referal. Cannot you simply refer me as I gave you the green light to do that from the get go.

Hi, David,

I'm sorry but there is no generic that works the way that Actos and Avandia do, or that will provide their level of glycemic control. The best method to control costs is to increase the insulin dosage and drop the glitazone altogether. That along with careful control of diet and exercise usually takes care of both pre- and post-meal glucose levels. Your endocrinologist will need to experiment, but increasing the basal insulin and decreasing the generic oral that you take may be what works best. I've got some patients just on Lantus who are having better A1Cs that they did for years of oral meds plus insulin.

A. Schuyler, NP, Nurse Practitioner
Category: Health
Satisfied Customers: 16292
Experience: Board Certified NP, MS, RN. 25 years private practice & hospitalist
A. Schuyler, NP and other Health Specialists are ready to help you
Customer: replied 8 years ago.
I just now see this is a place where I guess I could have asked a ? before going to the payment and rating area, I am not real good on the PC and this website isnt the easiet for me to figure out the flow of it I commented that a change from a neutral rating would be forthcoming upon addressing the other classes of oral meds that have possible generics that may complement using more Lantus. The doctor I saw in Jan told me to bump up the lantus PRN when he took me off Novolog and added Metformin.

Wow, I don't really like your doctor's plan. Lantus is a basal insulin that lasts up to 24 hours. It isn't something you want to give PRN but on a set schedule. Many patients take nothing but Lantus. Others require metformin as well.

The alpha-glucosidase inhibitors prevent the digestion of carbohydrates. They are taken before each meal. They are most useful for reducing postprandial glucose since they prevent the conversion of carbohydrate to glucose. With less glucose available for absorption, the glucose available to go into the blood is lower. Since the carbohydrates aren't digested, they remain in the colon where the intestinal bacteria work on them and can cause gas, bloating, abdominal pain, flatulence and diarrhea. This is the number one reason people stop taking the drug. Depending on the diet, they have the potential to lower A1C from about 0.5 to 1.0%. They are contraindicated in any kind of intestinal disorder (irritable bowel syndrome, Crohn's, etc.) or liver disease. Generics are available but they aren't a lot less expensive than the brand names (Precose, Glyset).

The amino acid derivative nateglinide (Starlix) does not have a generic. It works by helping your pancreas release more insulin and is taken beofre each meal. It is not as effective as glyburide and some of the other oral agents. I've never had a patient on this, so have no pointers to pass along.

The dipeptidyl peptidase-4 inhibitor sitagliptin (Januvia) also works by regulating insulin levels. It is not approved for use with insulin.

Repaglinide (Prandin) is taken before each meal to increase secretion of insulin. It binds to the beta cells of the pancreas and has very short duration.

The last part of your feedback comments were cut off, so I can't remember exactly what types of drugs you knew about and which ones you don't. Since you are taking metformin and glimepiride, I assume you understand how they work.

Customer: replied 8 years ago.
lt;p> You didnt read carefully enough what the endocrinologist had me do. I said he told me to bump up the Lantus PRN when he had me quit using Novolog.. I have always used it each evening on a regular schedule. I bumped it up or increased it enough to maintain good readings. Went up about 7 units. I take the actos(30mg),metformin(2000mg), glimepiride(8mg),and Lantus(30 units). No room to bump up the glimepiride and not a lot on the metformin. </p><p> The alpha-glucose inhibitors dont sound very hopeful. Januvia is out(didnt help much anyway when I tried it 2-3 yrs ago during my pre-insulin days).So repaglinide may be the best option if the generic is approved. The patent on Pradin was to expire in March nad hard to get specfic data on that. A generic companyCaraco) who fired for approval has been closed mouthed and I corresponded with the FDA a few weeks ago by email and they had nothing specfic either. I have sheets with all the diabetic drugs,what they do,and when the name brand got their first patent. </p><p> You didnt say whether generic prandin( when available) would be a good option to try</p><p> </p><p>Thanks </p>

There is no generic for Prandin yet but it is marginally cheaper to use than Actos.

I think I did read your original question clearly. You stated that your doctor advised you to bump up your Lantus PRN when you stopped Novolog. PRN means to increase the dose on an "as needed basis", just as you only take a Tylenol PRN when you have a headache. Lantus is not prescribed PRN. As a basal insulin, the same dose is taken daily.

As for whether it would be good to use, it wouldn't be my first choice, but it is a possibility. I'd titrate the Lantus upward unless you started to get hypoglycemic episodes, then lower it just to the point where you didn't. That should be all you need to keep your glucose under control without adding another medication (with its side effects) to the mix.

A. Schuyler, NP, Nurse Practitioner
Category: Health
Satisfied Customers: 16292
Experience: Board Certified NP, MS, RN. 25 years private practice & hospitalist
A. Schuyler, NP and other Health Specialists are ready to help you
Customer: replied 8 years ago.
lt;p> Thanks for the comments and patience. I should have used the word titrate when I was trying to explain that the doc advised me to titrate the Lantus when I discontinued the Novolog. He told me that I would very likely need to increase the Lantus some even after reaching the total of 2000mg of metformin. He also gave me the leeway of increasing the metformin faster than just by 500mg every 2 weeks. In fact , I was at 2000mg in 5 days. After gum disease surgery in my entire mouth, I have tried very hard to maintain good control and have not had an a1c over 6.5 since the fall of 07 with a 6.1 average since then.</p><p> No need to reply and I will go and give you an excellent review.</p><p> </p><p> </p>
Thanks so much. As a third-generation diabetic as well as a practitioner, I can tell you that you are achieving wonderful results. I wish all my patients had your tenacity and commitment to stay healthy. Good luck :-)
Customer: replied 8 years ago.
I think you will like my comments much better this time. I am also a 3rd generation diabetic through my mother's side of family and at least the 4th generation male with severe,gradual hearing loss from my father's side of family(I am very close to deaf in both ears now). I am fortunate that the hearing loss did not begin until well after a post lingual age, in fact I was able to get an accounting degree,become a CPA , and worked in healthcare financial jobs for my entire career. I was a hospital chief financial officer the last 22 yrs of that career and loved it,just too many years of too many hours.
Thanks so much.