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Insulin for dementia?

NAS80838

My wife has poorly controlled Type 2 along with worsening memory loss and now recurring UTI. Metformin, which she has been taking for 19 years, hasn't helped for a long time. Going for a new consult at a memory clinic on the 18th. There is evidence, however tenuous, that insulin, especially intranasal, can reduce symptoms. Any experiences to share regarding insulin and dementia? Thanks.

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  • No experience with insulin either, but piggybacking on this comment to add some diabetes practice guidelines from my wonderful primary care mentor:

    TIER 1: METFORMIN

    TIER 2: SGLT-2 inhibitors such as Empagliflozin, Canagliflozin, Dapagliflozin; some are in combination with metformin or DPP4 inhibitors, and those are even more expensive; GLP-1 agonists (only Semaglutide is oral, and is pretty expensive and hard to acquire too in the Philippines); other GLP-1 agonists like Liraglutide are available in combination with long-acting insulin

    TIER 3- DPP4-inhibitors- probably the safest and most tolerable but not the most efficacious and boasts less benefit for other organs like heart and kidney which are present in TIER 1 AND 2

    TIER 4- Thiazolidinediones (TZD), sulfonylureas-efficacious but notorious for causing hypoglycemia

    TIER 4 is preferred when there are financial constraints

    TZD- associated with weight gain and can worsen outcomes in patients with heart failure. Sulfonylureas are associated with poorer outcomes in patients with existing CVS disease.

    Taking a break from quoting my mentor, this is now me speaking as a medical student: I have yet to read a case on metformin refractoriness actually- esp. in the Philippines where clinical practice guidelines- maximize use of metformin. I can get back to you if I read something good.

    Going back to quoting the mentor: Metformin is only really avoided if there is allergy and poor tolerability, mostly due to vomiting, GI upset, diarrhea, etc.

    TIER 5 (last tier)- alphaglucosidase inhibitors, other drugs/interventions for obesity if present

Reply

  • No experience with insulin either, but piggybacking on this comment to add some diabetes practice guidelines from my wonderful primary care mentor:

    TIER 1: METFORMIN

    TIER 2: SGLT-2 inhibitors such as Empagliflozin, Canagliflozin, Dapagliflozin; some are in combination with metformin or DPP4 inhibitors, and those are even more expensive; GLP-1 agonists (only Semaglutide is oral, and is pretty expensive and hard to acquire too in the Philippines); other GLP-1 agonists like Liraglutide are available in combination with long-acting insulin

    TIER 3- DPP4-inhibitors- probably the safest and most tolerable but not the most efficacious and boasts less benefit for other organs like heart and kidney which are present in TIER 1 AND 2

    TIER 4- Thiazolidinediones (TZD), sulfonylureas-efficacious but notorious for causing hypoglycemia

    TIER 4 is preferred when there are financial constraints

    TZD- associated with weight gain and can worsen outcomes in patients with heart failure. Sulfonylureas are associated with poorer outcomes in patients with existing CVS disease.

    Taking a break from quoting my mentor, this is now me speaking as a medical student: I have yet to read a case on metformin refractoriness actually- esp. in the Philippines where clinical practice guidelines- maximize use of metformin. I can get back to you if I read something good.

    Going back to quoting the mentor: Metformin is only really avoided if there is allergy and poor tolerability, mostly due to vomiting, GI upset, diarrhea, etc.

    TIER 5 (last tier)- alphaglucosidase inhibitors, other drugs/interventions for obesity if present

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