Too Many Diabetes Drugs Simultaneously and Drug Interactions

I have been working on the analysis of a new study we just completed focused on 18 oral diabetes medications.

Part of the analysis is looking at the medications that patients are taking and the potential impact on the performance of their diabetes drugs.

First, I am struck by the fact that many patients are on many drugs simultaneously. It seems that if one drug is not working, then they are prescribed another to add on top without any analysis of why that initial drug didn't produce the desired results. Yes, some patients are on a more obviously structured approach of shorter-acting combined with longer-acting products. Others, though, seem to have the kitchen sink thrown at them. This approach seems unique to diabetes type II. I can't say that I see this in anyother disease state; even cancer with its cocktails and combination therapy is quite disciplined.

Ok, so what are we seeing. First, patients get prescribed a drug at diagnosis, not uncommonly, Metformin. So patients' initial physical response is supposed to be (1) reduction in blood glucose, (2) reduction in hA1c, and/or (3) side effects or not. If the patient's numbers don't improve, I typically don't see evidence that the patient and the physician sit together and ask why. (We'll skip the fact that physicians tend to ignore patient complaints of side effects with Metformin and therefore, patients are not taking the drug as prescribed in many, many cases - which would be why).

What we do see is that patients will be prescribed another drug to put on top of Metformin, not always switched, just added to. And sometimes that happens again and again. Drugs don't always get removed from the regimen, just added to. And dosing schedules get complicated.

Each time a drug is added, several things can happen. First complicated regimens are hard for patients to keep up with. Second, these drugs can have interactions both with each other and with other non-diabetes drugs. Some diabetes drugs interfere with one another creating hypoglycemia and/or unstabled blood glucose numbers, which is maddening for patients who can't seem to get their numbers under control. Next, physicians see the lack of control and more often than not, blame the patient without always scrutinizing the whole process.

At some point, sometimes quite confusingly for patients, the drugs all get swamped out for a new set. Sometimes patients just start on one new drug. But the pattern starts again of adding but not subtracting until the next critical mass happens.

The pattern doesn't necessarily change if the patient starts on insulin. At first, insulin seemsused alone but that doesn't always last and oral meds are added back.

At the same time, patients are working changing their diet and exercise patterns, which also impacts drug performance at the original dosing regimen many times resulting in hypoglycemia. And with patients on multiple drugs at one time, the non-diabetes drug interactions grow - birth control and blood pressure meds, NSAIDS, thyroid drugs, some antibiotics, asthma meds - all increase risk for both hypoglycemia and hyperglycemia simultaneously. No wonder so many people can't get their numbers under control.

The whole process doesn't seem the best way to tackle what is called an epidemic. Many patients do figure it out with hard work and lots of research. But a lot more don't.

So more drugs on the market is not going to make this better. Diabetes needs a better approach that figures out why some medications work and others don't, how diet and exercise really impact medication needs, and how to reliably stop the advance of the disease. The kitchen sink approach is not a long-term strategy.