06 September, 2015


Modern medicine has lots of wonders up its sleeves... So do the pharmaceutical companies that manufacture the wonders required for maintaining health. The classical methodology of treatment was using monotherapy (simply speaking its one drug at a time). In diabetes this policy doesn’t work. As I have discussed in many of my previous posts Diabetes is multi-factorial and so does the modality of treatment. Combination therapy is the norm in treatment of Diabetes. We need to squeeze out the insulin from the pancreas plus make the squeezed out insulin work better by increasing the body’s sensitivity to insulin plus reduce the carbohydrate absorption from the food we take... Generally I prefer to start treatment by giving individual medicines. Once the patient’s blood sugar is under control we can try combination of tablets. The logic behind combining is to simplify the treatment schedule for the patient. Lesser number of tablets means more patient satisfaction.

Until recently major pharmaceutical companies were providing combinations of Sulphonylurea (To squeeze out the insulin) and biguanides (to increase insulin sensitivity). These combinations were wonderful to use and by far helped to reduce the complexity in dosing and increased patient compliance. Pre and post Pioglitazone controversy witnessed emergence of sulphonylurea, metformin and Pioglitazone combos.

The latest combination being marketed by many major pharmaceutical companies is a combination of Glimipiride, Metformin and VOGLIBOSE. This combination somehow doesn’t impress me. Why?
Well, the most effective way to obtain maximum effect of a drug is to follow the timing of the drug.
  • Sulphonylureas need to be taken 30minutes before food.
  • Metformin can be taken before meals or after meals.
  • Voglibose needs to be taken just before food or in between food.

The replies I got when I posted the same question to the pharmaceutical companies are just hilarious.
Here are a few:
  • Sir, we can give this combination tablet 15mins before food... (If so how do I know for certain that the glimipiride is acting to its full potential?)
  • Sir, This combination is developed as per the suggestions given by your colleagues.... (Crap... There is nothing called research? )
  • This is a good one - Sir, Even I don’t personally favour this brand in my company! (What..... ahem... No Comments!)

Personal search on Google Scholar did reveal a few results. Nothing satisfactory...
Looks like sponsored research. J

I am not here to criticize any particular brand. The intention behind this blog post is
  1. Do not blindly believe pharmaceutical reps. Most of them are untrained.
  2.  Your patients need quality treatment so treat them with what you know the best.
  3.  Be choosy on CMEs you attend. Most of them are sponsored by pharmaceutical companies and hence speakers even though eminent, try to support the sponsors.
  4. Voglibose can be given separately. In case of gastrointestinal symptoms it will be easy to withdraw the offending molecule without major changes in the prescription.
  5.   Respect each drug. Give it proper time to act. Treat your patients with conscience.

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