**9. Avoiding unnecessary medicines and products**

as possible. Physical activity and exercise increases glucose utilization and reduces blood glucose. Thus, there is need of continuous effort to reduce the dose of sulfonylurea, repaglinide and insulin to the lowest possible level as the '*Dynamic dose management of medications likely to cause hypoglycemia*' letting the healthy lifestyle and other non-hypoglycemic antihyperglycemic drugs to maintain the blood glucose [50]. Patient education and guidance from family physicians, diabetes educators and other health care workers will help to achieve such

Geoffrey Rose rightly highlighted 'Safety is paramount with long-term interventions' [9]. There is relatively longer history of safety profile with metformin and acarbose. They are preferred in the prevention and in the early phase of treatment of diabetes so that they can be

Based on such principles, a suggested approach of antihyperglycemic therapy is outlined in

Compared to the two agents prescribed separately, combination tablets reduce pill burden and help adherence of patients [49]. However due to the contrasting effect as well as the need of 'dynamic dose adjustment of medications likely to cause hypoglycemia' to the lowest possible dose and of gradual building of the dose of metformin for its continued maintenance at the optimum level, the formulation of fixed dose of combination of such drugs in a single tablet is irrational (**Table 2**) [50]. Availability of such fixed dose combination formulation in the market is likely to lead to the continued usage of sulfonylurea and suboptimal dosage of metformin even right from the time of diabetes diagnosis with all its

**Metformin Sulfonylurea or repaglinide**

minimize hypoglycemia

maintained

Difficult and likely to cause hypoglycemia if the optimal dose of metformin is targeted or

Principle of use To maintain optimum dose To keep the dose as minimum as possible to

\*Apart from the risk of effect of severe hypoglycemia on heart, it is also advised that use of the sulfonylurea types (glibenclamide, glipizide, glimepiride and others) that bind the sulfonylurea receptor-2 A and B should be avoided in

**Table 2.** The contrasting effect and uses of metformin and sulfonylurea and repaglinide making their fixed dose

Hypoglycemia risk Neutral Moderate to severe

Major cardiovascular events Beneficial Generally neutral\*

Administration Usually after meal Usually before meal†

Difficult and the dose is likely to be suboptimal due to the fear of inducing hypoglycemia

Effect on bodyweight Slight loss Gain

high-risk patients suspected of having significant coronary artery disease [51].

Sulfonylureas are often advised to be taken at least 15–20 minutes before a meal [51].

dynamic dose management.

188 Diabetes and Its Complications

**8.5. Long-term safety profile**

safely continued for long time.

algorithm in **Table 1**.

effects in the patients.

Dose adjustment with combination tablet

combination formulation irrational.

†

There is no clear evidence that dietary supplementation with vitamins, minerals, herbs or spices can improve outcomes in people with diabetes who do not have underlying deficiencies, and there may be safety concerns regarding their long-term use [25]. Unnecessary medication or local herbal, traditional or plant products may increase the cost and/or number of tablets to be taken which can affect the adherence to the essential medicines. Any medications or various products are also some form of chemicals and can also cause side effects, affect different organ systems or interact with other medications [52]. It is a famous saying 'Everything under the sun, including the sun, can cause allergy or side-effects'. For example, peripheral edema may occur in up to 16% with pregabalin [53]; however, amlodipine, a useful and essential medicine for hypertension, may instead be inadvertently stopped due to its well-known association with peripheral edema. Symptoms like tingling, numbness or others may need to be investigated. However, if treatment does not change the course of the condition and if symptoms do not affect sleep or daily life of the patients, explanation and reassurance with the required follow-up may be preferred than using unnecessary medications.

**Research perspectives:** State may develop some support system (e.g. by making available research funds or by involving pharmaceutical companies or other donor agencies) to study the local herbal, traditional or plant products and to identify and isolate the active the pharmacological ingredient of such possible crude products [52].
