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[e-drug] Combining oral hypoglycaemics? (4)

E-DRUG: Combining oral hypoglycaemics? (4)

Dear Olutayo,

I am really happy that you have decided to take
advantage of the E-Drug forum, as an hospital
pharmacist in Nigeria, to contribute meaningfully to
improving the quality of care offered patients in
Nigerian hospitals. Notwithstanding the various
man-made barriers instituted by Nigerian physicians
who are maintaining a vice-like dominance of the
Nigerian health care health system. This is no empty
observation, I am actively involved in
Pharmacoepidemiology and outcomes research at various
levels of care in Nigeria and I know the unnecessary
hassles I go through, with physicians who are often in
charge of everything in our health care system, in
conducting these studies that are sincerely designed
to foster better outcomes of use of pharmacotherapy in

Now coming to your questions, It is not only
absolutely wrong to prescribe a combination of
Chlorpropamide and Glibenclamide with Meformin, It can
endanger the patient's life. What about it anyway.
Only God knows how many deaths are recorded due to
such negligence on the part of Nigerian doctors who
often feels that no one with in the health care
sysytem should dare to question their judgement.
Anyway let leave that for another day.

Chlorpropamide is a 1st generation sulphonylurea with
a long plasma half life of 36 hours and the usual
starting dose is 250mg daily with a maintance dose
range of 100-350mg. The risk of severe and prolonged
hypoglyceamia, liver and abdominal disturbances, for
which the elderly are highly susceptible, is highest
with sulphonylureas with long plasma half-life i.e
Chlorpropamide and even Glibenclamide( a second
generation sulphonylurea usually given as 2.5-5mg
daily).  Studies have shown that optimal efficacy is
best achieved at lowest effective dose, additional
increase in dose will only increase propensity of side
effects, as its the case cited by Olutayo.

Although, Biguanide(Metformin)has synergistic effect
with sulphonylureas, troubling abdominal discomfort is
a major problem with the drug. The more reason while
the strategy of slowly escalating the dose has to be
employed. i.e You can start with 500mg daily, increase
after a minimum period of about a week to 500mg
12hourly and then to  500mg 8hourly to a maximum dose
of 3g. per day.

Of course as it has been pointed out, care must be
taken to exclude renal and liver failure and/or
impairment, congestive heart failure.

Therefore the rational choice should be Chlorpropamide
or Glibenclamide plus Metformin.

The impressions I have looking at the combinations
Olutayo cited are:

 1. The patient may have problems with dietary
restrictions as this has been to shown to be a major
cause of poor glycaemic control among daibetics.

 2. The patient is experiencing some yet to be
uncovered and drug-use related problems; this is where
the job of Olutayo comes in. I have just completed an
intervention studies (Pharmacist medication review
clinic at the Medical Outpatient Clinics of a premier
Teaching Hospital in Nigeria. The results of the
exercise were indeed revealing. It was also extremelt
tough getting the authorities to allow me do the
study. It was the concluding part of my doctoral

Bravo brother keep it up. The face of hospital
pharmacy practice in Nigeria is changing for the
better and with people like taking advantage of an
excellent resource like the E-Drug. Things can only
get better. 


Kazeem Babatunde Yusuff
Dept. of Clinical Pharmacy & Pharmacy Administration
Faculty of Pharmacy
University of Ibadan
Ibadan, Nigeria.
e-mail: yusuffkby@yahoo.co.uk

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