LF doctor opinion

[sylke]

Something didn't sound right to me.

http://community.livejournal.com/pcosupport/578106.html?nc=1

The commenter writes that she takes breaks from Metformin to "detox for [her] liver's sake". Now, what I thought about how Metformin works is that it actually decreases the stress on your liver. Met changes liver function so it's not producing as much glucose, reducing overall blood sugar which eases the strain on the insulin-producing pancreas. Now, you shouldn't drink very much while on Met, because the liver won't process it as well or correctly, and having liver disease is a definite contraindication for taking it. But is there any medical advantage at all to taking a break to "detox" from Met? Personally, I take a break from time to time, but that's simply an aversion to swallowing large pills and it being so easy to get out of the habit of taking them daily.

bluekitsune? jvinocur? jfrands? Feel free to chime in, I'm looking at you folks for commentary. (vetgirlbeth, your input would also be valued if you care to comment on diabetes medications in non-humans :)) My apologies if I forgot any other members of the medical community.

Comments

[amdiranifani.livejournal.com]

My professional opinion is that one should drill a hole in the skull to let the evil spirits out every once in a while.

[vetgirlbeth.livejournal.com]

So this comes from a very brief survey of the literature out there, and could be faulty as such:

My understanding is that while it's not clear the exact mechanism of action of Metformin, it may be associated with the inhibition of activation of a certain enzyme (AMPK) in the body - which is predominantly in the liver, but also in other tissues, and this is potentially how it has all it's effects.

That said, stoping the metformin to "detox" without any clinical reason for it is not a choice with any medical basis. I can fully understand the notion of drugs losing efficacy with prolonged use. The body is an amazingly resilient thing, and given enough time can change it's makeup in the face of various medications. For example, prolonged use of prednisolone can lead to decreased efficacy as the body essentially adjusts to it (increases clearance, decreases receptors that respond to it, etc.) and so it stops working. Stop the drug for a few months, and you can start it again like new because all those changes revert to normal (this effect has been documented in dogs with atopic dermatitis that require chronic steroid therapy). Therefore, I could comprehend a similar effect in other drugs. So if the metformin stopped working, I would understand the lay-person referring to stopping the med as "detoxing their liver," allowing the changes that the drug made to revert to normal. However, if they drug is working great, the notion of stopping it seems (frankly) ignorant to me. Perhaps she just has a misunderstanding of how the drug works. That's the kind of thing she and her endocrinologist should have a little sit down about. If stopping it doesn't hurt her, whatever, more power to her, but she's not doing it for an actual medical reason. She probably stops for the same reasons you do, but tries to rationalize it to herself as something medical.

As for Metformin's specific usage in animals, it's been through some trials as a anti-diabetic agent in cats, but the jury is still out in the literature on whether it's useful or not. Some cats can be controlled with just dietary changes, and ostensibly Metformin would work in this group (cats are about 50/50 type one and two diabetes, whereas dogs are 99% type one) but there's not alot of clinical data yet to support it.

My 99c (was too big for just 2c).

[sylke.livejournal.com]

As turkeygirl posted below, there are some supremely stupid people on teh intarweb. However, even given that, I've never heard reports in the Forum Of Whining of Met losing its efficacy over time. Looking back at the post, this is the same commenter who refused to take the recommended dosage of her medication, and I would guess she didn't take the full dose for long enough to adjust.

Thanks for the info! I'd totally pay a buck for a comment that included a lit search. ;)

[jvinocur.livejournal.com]

I generally agree with Beth. There can be important adverse effects from metformin, and people may need bloodwork for monitoring, but I'm not sure we really do drug holidays with metformin.

Regardless, it's pretty much never the right idea to take a drug holiday on a whim. I mean, the whole point of going to a specialist is because they know more about this...and if you don't trust your doc, you should find a new one, not start doing things behind his back :-)

[sylke.livejournal.com]

So, there are other drugs that do indicate a drug holiday from time to time? It makes sense, given the variety of side effects that some drugs have and the inevitable strain on various parts of the body, but I don't believe I'd heard of a prescribed holiday before. Then again, I'm a little young and a little too healthy to be taking anything particularly hard core.

I am completely open and honest with my specialist. I told him up front that I was taking a break because I don't like the big pills. ;) 4 pills at night is right at my borderline, and my understanding of *why* I'm taking the Met is that it makes my body work a bit better (extraordinarily layman terms here) and reduces my chances of getting Type II diabetes later in life, which is also manageable by diet. So honestly they feel kinda optional. What's the word for people like me? Noncompliant? ;)

[jvinocur.livejournal.com]

There certainly are drugs where holidays are even recommended (see what google scholar finds for "drug holiday").

And you really don't want to make it any closer to frank diabetes than you can manage, btw. It puts you at substantially increased risk for heart disease, kidney disease, blindness, leg ulcers, and probably other stuff I thankfully don't have to deal with any more.

Incidentally, we're supposed to say "nonadherent" instead of "noncompliant" now, for some reason.

EDIT: fix broken formatting, *sigh*

[turkeygirl.livejournal.com]

Don't forget, this is also the forum that brought us, 'I think I may be pregnant but I don't think I can be because I was on birth control at the time. Every time I had sex with my bf I took one of the pills. I made the pack of pills last for almost a year!' Or whatever it was. People on the Intarweb are, on average, really stupid.

Speaking of which, I always just want to /scream/ at the people on there who are like, 'I WILL NOT TAKE MEDICATION MEDICATION IS BAD AND UNNATURAL BUT I WILL TAKE TEN DIFFERENT HERBS WHICH HAVEN'T BEEN TESTED BY THE FDA!' ...But that's a tangent.

My endo always takes a measure of liver function when he takes blood for the PCOS. It's always totally normal, so I don't worry. The benefits -way- outweigh the costs. No cravings!

[sylke.livejournal.com]

Oooh, I'd missed the "pack of pills lasted a year" post. Yeah, they are stupid, and I figured this was one of those, but some strains of stupidity that are refutable really easily drive me to actually try to comment and generally ease the overall strain of Teh Stupid in the universe. This isn't a person who will be swayed by "The benefits outweigh the costs," because if there's any meds that take up residence in her liver, she'll feel she needs to detox. But if as I understand from Beth's post above, the Metformin isn't collecting in the liver so much as (believed to be) inhibiting an enzyme the liver is 'known' for, then there's no 'toxin' so to speak. OTOH, since Met's function isn't really fully understood, there's a loophole for Teh Stupid to get out no matter what we *do* know about it.

I wanna be a doctor now, doctors are cool. :P Can I go to med school?

[mg4h.livejournal.com]

If you haven't found this website already, you might enjoy taking a look around. Here's an entry for metformin Hcl. From reading through that, there's no testing they've done on people with hepatic impairment, but they have done tests on renal impaired folks, because one of the serious side effects of metformin Hcl is lactic acidosis, which is pretty darn fatal (50% die).

It seems while metformin does do stuff to and for the liver, it doesn't actually go through it. But the kidneys have to process the darn stuff, and that can put a strain on them.

So either she's stupid and confused liver for kidneys, doesn't understand how this stuff works, or is actually resistant to it after a while. But there's no detoxing of the liver that's going on there.

[jfrands.livejournal.com]

regexp *detox* -> /dev/null

Just about any paragraph with that word except in referrence to a place to come down from alcohol should be ignored. It has no physical meaning. The idea that your kidneys or liver need to be detoxified is created by the mistaken notion that they act like literal filters that collect garbage. The liver uses enzymes to slice and dice things until they are small enough for the kidney to actively excrete them. It does though also process and store glycogen and is instrumental in procesing lipids, as well as having endocrine and exocrine functions, some of which we don't understand at all.