Metformin should be stopped at the time of or before administering iodinated contrast in patients with an eGFR between 30 and 60 mL/minute/1.73 m2; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Kidney function should be evaluated 48 hours after receiving contrast and metformin may be restarted if kidney function is stable.
Medications in this drug class may reduce the risk of heart attack and stroke in people with a high risk of those conditions. Side effects may include vaginal yeast infections, urinary tract infections, low blood pressure, and a higher risk of diabetic ketoacidosis. Canagliflozin, but not the other drugs in the class, has been associated with increased risk of lower limb amputation.

Left untreated, hyperglycemia can lead to a condition called ketoacidosis, also known as diabetic ketoacidosis (DKA) or diabetic coma. This occurs because the body has insufficient insulin to process glucose into fuel, so the body breaks down fats to use for energy. When the body breaks down fat, ketones are produced as by-products. Some ketones are eliminated via the urine, but not all. Until the patient is rehydrated, and adequate insulin action is restored, ketones remain in the blood. Ketones in the blood cause nausea, headache, fatigue, or vomiting.


The chart above gives averages. Follow your doctor’s advice on when and how to take your insulin. Your doctor might also recommend premixed insulin, which is a mix of two types of insulin. Some types of insulin cost more than others, so talk with your doctor about your options if you're concerned about cost. Read about financial help for diabetes care.
If you are having surgery, including dental surgery, or any major medical procedure, tell the doctor that you are taking metformin. Also, tell your doctor if you plan to have any x-ray procedure in which dye is injected, especially if you drink or have ever drunk large amounts of alcohol or have or have had liver disease or heart failure. You may need to stop taking metformin before the procedure and wait 48 hours to restart treatment. Your doctor will tell you exactly when you should stop taking metformin and when you should start taking it again.
In those with polycystic ovarian syndrome (PCOS), tentative evidence shows that metformin use increases the rate of live births.[35] This includes in those who have not been able to get pregnant with clomiphene.[36] Metformin does not appear to change the risk of miscarriage.[35] A number of other benefits have also been found both during pregnancy and in nonpregnant people with PCOS.[37][38] In women with PCOS undergoing in vitro fertilization, evidence does not support a benefit with respect to live births.[39] The evidence does not support general use during pregnancy for improving maternal and infant outcomes in obese women.[40]

There are also new treatments for Type 2 diabetes, including medications that can help your body produce more insulin (leading to better blood sugar control) or improve your body’s sensitivity to the insulin it already makes. Some of these new drugs change the way blood sugar is released in your body. Other drugs help control blood sugar, lower the risk for heart disease and promote weight loss. The side effects will vary based on the drug, but they can include digestive problems, an increased risk for heart failure or urinary tract infections.

If your cells aren't getting glucose, they are literally being starved of energy. That can make you feel like you're always tired. When your blood is thicker and more viscous due to elevated blood sugar, your heart has to work harder to pump it, and it moves more slowly throughout your body to deliver nutrients to your cells. Additionally, when your body gets rid of excess sugar in the blood through urination, you're literally flushing energy out of your body and into the toilet. Plus, increased thirst and urination means more nighttime trips to the bathroom, interrupting your sleep. 
Hyperglycemia or high blood sugar is a serious health problem for diabetics. There are two types of hyperglycemia, 1) fasting, and 2)postprandial or after meal hyperglycemia. Hyperglycemia can also lead to ketoacidosis or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). There are a variety of causes of hyperglycemia in people with diabetes. Symptoms of high blood sugar may include increased thirst, headaches, blurred vision, and frequent urination.Treatment can be achieved through lifestyle changes or medications changes. Carefully monitoring blood glucose levels is key to prevention.
^ Jump up to: a b Angelico F, Burattin M, Alessandri C, Del Ben M, Lirussi F (January 2007). "Drugs improving insulin resistance for non-alcoholic fatty liver disease and/or non-alcoholic steatohepatitis". The Cochrane Database of Systematic Reviews. 24 (1): CD005166. doi:10.1002/14651858.CD005166.pub2. PMID 17253544. (Retracted, see doi:10.1002/14651858.cd005166.pub3. If this is an intentional citation to a retracted paper, please replace {{Retracted}} with {{Retracted|intentional=yes}}.)
Metformin should be stopped at the time of or before administering iodinated contrast in patients with an eGFR between 30 and 60 mL/minute/1.73 m2; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Kidney function should be evaluated 48 hours after receiving contrast and metformin may be restarted if kidney function is stable.

If extended tablets are used, the starting dose is 500 mg or 1000 mg daily with the evening meal. The dose can be increased by 500 mg weekly up to a maximum dose of 2000 mg except for Fortamet (2500 mg of Fortamet, once daily or in two divided doses). Glumetza tablets (500 -1000mg formulations are given once daily (either 1000 to 2000mg). Fortamet and Glumetza are modified release formulations of metformin. Metformin should be taken with meals.
Regardless of which type of diabetes one has, the results are the same. Hyperglycemia, or abnormally high concentrations of blood sugar for extended periods of time, are first detected after the sufferer experiences such symptoms as unusual thirst, constant urination and hunger, profuse sweating, dizziness and a general sense of disorientation or malaise, NIDDK reports. Inside the body, high concentrations of blood sugar can begin damaging sensitive tissues and organs and can ultimately cause a complete failure of systems, according to NIDDK. Hyperglycemia accelerates coronary artery disease, causes kidney failure and, if left uncontrolled, can lead to loss of vision, nerve damage and amputation of limbs.
Often, people with type 2 diabetes start using insulin with one long-acting shot at night, such as insulin glargine (Lantus) or insulin detemir (Levemir). Discuss the pros and cons of different drugs with your doctor. Together you can decide which medication is best for you after considering many factors, including costs and other aspects of your health.
^ Hemmingsen B, Schroll JB, Wetterslev J, Gluud C, Vaag A, Sonne DP, Lundstrøm LH, Almdal T (July 2014). "Sulfonylurea versus metformin monotherapy in patients with type 2 diabetes: a Cochrane systematic review and meta-analysis of randomized clinical trials and trial sequential analysis". CMAJ Open. 2 (3): E162–75. doi:10.9778/cmajo.20130073. PMC 4185978. PMID 25295236.
Numb toes and tingling fingers—a condition called peripheral neuropathy—can be a sign that your blood sugar has been too high, for too long. The ends of the longest nerve fibers in the body are usually the first to suffer, according to the American Academy of Neurology. That’s why the feet, legs, arms, and hands are all vulnerable. Nerve damage to the extremities can produce a range of symptoms, from burning or prickling to shocking pain. Controlling blood sugar levels can prevent further damage. “But if it’s been going on for a while and the sugars have been high for years, then it probably won’t go away,” says Terri Washington, MD, an endocrinologist at Diabetes, Osteoporosis, Obesity Inc., in Oak Lawn and Amherst, Ill.
Treatments depend entirely on the type of nerve damage, symptoms, and location. Your doctor will explain how nerve damage is causing specific symptoms and how to minimize and manage them. With proper education, some people may be able to reduce their medication dose or manage their neuropathy without medications. Definitive treatment can permit functional recovery over time, as long as the nerve cell itself has not died.
About three-fourths of polyneuropathies are “length-dependent,” meaning the farthest nerve endings in the feet are where symptoms develop first or are worse.  In severe cases, such neuropathies can spread upwards toward the central parts of the body. In non-length dependent polyneuropathies, the symptoms can start more toward the torso, or are patchy.
Type 1 diabetes is responsible for about 5% of all cases of diabetes and results from damage to the insulin-secreting cells of the pancreas. Type 2 diabetes is far more common and is related to the body's inability to effectively use insulin. In addition to type 1 and type 2, gestational diabetes is a form of diabetes that develops in pregnant women. Studies show that between 2% to 10% of all pregnant women get gestational diabetes.

The FDA most recently revised its prescribing information on metformin in 2016.[57] Current advice is that metformin is contraindicated in people with 1) severe renal impairment (estimated glomerular filtration rate (eGFR) below 30 ml/min/1.73 m2); 2) known hypersensitivity to metformin; or 3) acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. Warnings are also given regarding the use of metformin in less severe renal impairment, people aged 65 years old or greater, hypoxic states (e.g., acute congestive heart failure), excessive alcohol intake, hepatic impairment, concomitant use of certain drugs (e.g. carbonic anhydrase inhibitors such as topiramate), surgery, and other procedures, or in people having a radiological study with administration of an iodinated contrast agent.

Prediabetes is a condition in which a person has early symptoms of diabetes, but has not yet fully developed the condition. If prediabetes is not treated with lifestyle changes, the person could develop type 2 diabetes. Type 2 diabetes and prediabetes can be prevented with lifestyle changes, for example, eating a healthy diet, getting more exercise, reducing stress, quitting smoking, reducing or managing blood pressure and cholesterol, and managing any other health conditions or risk factors that you may have for developing type 2 diabetes.
In addition to suppressing hepatic glucose production, metformin increases insulin sensitivity, enhances peripheral glucose uptake (by inducing the phosphorylation of GLUT4 enhancer factor), decreases insulin-induced suppression of fatty acid oxidation,[95] and decreases absorption of glucose from the gastrointestinal tract. Increased peripheral use of glucose may be due to improved insulin binding to insulin receptors.[96] The increase in insulin binding after metformin treatment has also been demonstrated in patients with NIDDM.[97]
Exenatide (Byetta) was the first drug of the GLP-1 agonist group. It originated from an interesting source, the saliva of the Gila monster. Scientists observed that this small lizard could go a long time without eating. They discovered a substance in its saliva that slowed stomach emptying, thus making the lizard feel fuller for a longer time. This substance resembled the hormone GLP-1.
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