Most people diagnosed with diabetes or prediabetesstarting the drug, metforminplus recommendations on the importance of a balanced diet and regular exercise.

A change of life should be the number one goal for every diabetes patient, says the doctor Ricardo Correa, an endocrinologist at the Cleveland Clinic.“A healthy low-carbohydrate diet combined with 30 minutes of physical activity 5 days a week should be mandatory for all patients with diabetes.” The use of metformin, he adds, is successful if it is combined with these changes. But, Metformin can help in the early stages of the disease, but eventually more and more drugs will have to be added, all the way up to insulin.

Because of the latter, the difficulty for patients to adhere to a healthy lifestyle, some experts in the world of diabetology believe that monotherapy is not enough to reach these patients.

One of the proposals is the application of combined therapy. Doctor Angélica Valdivia Portugal, endocrinologist, is about a multicenter, randomized, double-blind clinical trial confirm (Published in Lancet2019), which compared a group of patients with type 2 diabetes (more than 2,000 people, including citizens of Colombia, Peru, Argentina, Brazil and Mexico) who received metformin monotherapy and another group that additionally received , a DPP- 4, in this case vildagliptin.

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The participants were aged between 18 and 70 years, with type 2 diabetes diagnosed no more than two years before enrollment in the study and glycosylated hemoglobin 6.5 to 7.5% and a body mass index of 22-40 kg/m².

“This study concludes that most patients are not able to maintain the target on all targets, especially glycemic control, And what does it mean to have a glycosylated hemoglobin of less than 7%”. Glycosylated hemoglobin, says Valdivia, is the gold standard in diabetes control. “There are other controls, but it should be less than 7%, of course, always personalizing the case of each patient.”

For her, this is a sign that conservative treatments must give way to proactive ones. “The initial therapy failed us and showed us that diabetes is a progressive disease and that monotherapy is useless,” he says. Why are you holding this? “(In average) when the patient is diagnosed, he has had the disease for 10 years and already has complications, that’s why we have to use intensive, proactive treatments, combined therapy, avoiding clinical inertia”.

Waiting, according to Valdivia, reduces the patient’s quality of life, which is one of the most important therapeutic goals. “We will live longer, the birth rate is lower and the life expectancy is higher. The problem is how we will live, that is, the quality of life”.

The advantage of combined therapy, according to the endocrinologist, is the avoidance of diabetes complications: retinopathy, neuropathy, kidney disease. 40% of the patients in the dialysis room are diabetic“. and although confirm not designed to target cardiovascular disease, suggests a 29% reduction in cardiovascular risk.

“What I have seen with these patients, whom I am still following, is that they age successfully, because there are no major complications other than diabetes. I see the quality of life, I repeat, that indicator that is important to observe as a therapeutic goal. Early combined therapy from diagnosis gives us numerous results and a better quality of life”.

For his part, endocrinologist Ricardo Correa confirms this The combination of drugs with different mechanisms of action helps to quickly lower glucose and glycosylated hemoglobin in patients with diabetes. And it explains the difference between vildagliptin and metformin. The first is a drug that inhibits the DPP-4 enzyme, which results in an increase in insulin in the body. Metformin helps the cell to be more sensitive to insulin.

“The combination of these two drugs mainly focuses on reducing glucose,” is Correa’s medical opinion, “and not so much on protecting other organs such as the kidneys or the heart.” In your opinion, there are other diabetes medications that take a more protective approach.

In addition, he notes that both drugs can only be given to patients suffering from type 2 diabetes. “There is no specific stage that would recommend them. It may be that the doctor starts with this combination from the beginning, or it may be that he starts with metformin alone and then adds vildagliptin.” It all depends on the glycosylated hemoglobin.

What to do in case of hypoglycemia?

Since diabetes is incurable, the patient must learn the path of his treatment and the goals. “Emotional diabetes does not exist,” says Dr. Valdivia, to emphasize that the disease will not simply disappear with a more peaceful life. “We have to achieve an objective goal, which is that a newly diagnosed patient has less than 7%” of glycosylated hemoglobin.

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“In fact, in some patients it should be less than 6.5%, always avoiding the risk of hypoglycemia,” says the doctor. DPP-4 inhibitors do not cause hypoglycemia. Because they are smart drugs, they release insulin depending on glucose, i.e. only if glucose is elevated.

When you come for a consultation, ask what your goal is, less than 6.5 or less than 7%, to achieve and maintain it and thus preserve the quality of life and avoid microvascular complications (kidneys, eyes, diabetic neuropathy) and macrovascular. “Achieving the goal within the first year of diagnosis strongly bodes well for the future of our patients.”

Learn more about hypoglycemia. A person with diabetes should not have glucose below 70 and therefore should use lower risk medications such as the top DPP-4 inhibitors. You need to master the technique of injecting insulin, because it is the drug with the highest risk of hypoglycemia.

Low blood sugar is dangerous in diabetes patients because it can be severe and cause seizures, coma or even death, Correa says. “It is always recommended that when a patient is taking insulin or a sulfonylurea (an oral non-insulin antidiabetic), they should be more aware signs and symptoms of low blood sugar, and that if they appear, the sugar should be measured. If it’s low, take juice or sugar tablets to raise it.”

What are the symptoms? “It’s normal to feel palpitations, sweating and weakness. What are the main causes of hypoglycemia?