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What Causes Fatigue And Muscle Pain After Taking Metformin?
Posted on
Sun, 30 Nov 2014
Medically reviewed by
Ask A Doctor - 24x7 Medical Review Team
Sun, 30 Nov 2014
Answered on
Mon, 22 Dec 2014
Last reviewed on
Question : I am 67 years, diagnosed type 2 diabetic, although the evidence points to LADA. I am also hypthyroid, following partial thyroidectomy in 1972. I am on insulin (Lantis and Apridra). Metformin was prescribed about five years ago, but when my HbA1c went up the doctor moved me from Metformin to Gliclazide. Over the next 10 months, the Gliclazide was increased to the maximum. My HbA1c was still not under 7.0, so a new doctor started me on Metformin and increased this to the maximum dose over a period of (just) 8 weeks. Around this time I began to get symptoms of extreme tiredness, lethargy and lack of energy and motivation. I also got the type of muscle pain you experience during the finishing sprint of a very fast 5000m race (exercise induced lactice acidosis?) except this would happen after walking just 200 or 300m. I could barely cope with doing anything, but somehow only about three people noticed how much I was struggling. After about a year of talking to the doctor about this (and getting responses like it was my age, and I should consider retiring, etc) I finally said the symptoms began with taking Metformin. The doctor said it couldn't be Metformin, but I said the only way to find out was to stop taking it and see what happened. The symptoms reduced quite considerably over the next few weeks, but then stablised at a level where I am fairly tired and lacking energy and motivation. These symptoms are not nearly so bad if my blood sugars are in the 3.3 to 5.5 (60-100) range. I suspect that I have some condition that is eased when my blood sugars are in the normal range. What do you think. (also I have diverticula and have been diagnosed with restless leg syndrome and my blood calcium has been at the bottom end of the normal range since the parathyroid complication to the 1972 partial thyroidectomy and I'm on calcium and calcitriol). Any ideas what may be causing the lack of energy, lethargy and tiredness?
Brief Answer:
Few questions
Detailed Answer:
Good day,
Noted your concern and feel sorry about your symptoms. However, i must say that Metformin is unlikely to cause these symptoms. There are several possibilities for your symptoms.
1) Hypothyroidism: What is your last TSH levels?
2) Vitamin D defciency
3) Low Calcium levels from Hypoparathyroidism: Do you have a recent blood calcium levels?
4) Muscle pain from Peripheral neuropathy
5) Muscle pain from low serum ptaasium
6) Muscle pain due to cholesterol pills. Are you taking a cholsterol lowering pill ?
I would appreciate a reply to above questions
Regards
Binu
Few questions
Detailed Answer:
Good day,
Noted your concern and feel sorry about your symptoms. However, i must say that Metformin is unlikely to cause these symptoms. There are several possibilities for your symptoms.
1) Hypothyroidism: What is your last TSH levels?
2) Vitamin D defciency
3) Low Calcium levels from Hypoparathyroidism: Do you have a recent blood calcium levels?
4) Muscle pain from Peripheral neuropathy
5) Muscle pain from low serum ptaasium
6) Muscle pain due to cholesterol pills. Are you taking a cholsterol lowering pill ?
I would appreciate a reply to above questions
Regards
Binu
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
The doctor tells me the blood tests for the thyroid and the calcium are good. I do take Vitamin D (Calcitriol 0.25mcg daily with Calcium). I have no idea about Potassium. There is no other symptom of neuropathy and I am taking a cholesterol lowering pill - Exetrol 10mg once a day.
My feeling is that Metformin wasn't causing the symptoms (as I haven't been taking it for over a year now), but rather exacerbating them. (The exception is the muscle pain after walking rapidly for 200 to 300 metres, which has disappeared. But then, that sounds like lactic acidosis to me and the FDA has a lactic acidosis warning on Metformin - not that this is relevant now as that symptom disappeared with dropping the Metformin. I do walk fast - around 8km/h.)
My feeling is that Metformin wasn't causing the symptoms (as I haven't been taking it for over a year now), but rather exacerbating them. (The exception is the muscle pain after walking rapidly for 200 to 300 metres, which has disappeared. But then, that sounds like lactic acidosis to me and the FDA has a lactic acidosis warning on Metformin - not that this is relevant now as that symptom disappeared with dropping the Metformin. I do walk fast - around 8km/h.)
Brief Answer:
Foot pulsus
Detailed Answer:
Yes, you are right. Metformin can cause lactic acidosis. However it is rarely seen. It is more possible when there is kidney failure.
Good to hear that symptoms reduced after reducing Metformin dose. What dose are you on now?
Calcitriol is not Vitamin D. It is activated Vitamin D ( 1, 25 hydroxy vitamin D).
Exetrol is Ezetemibe and it rarely cause Myalgia unlike many other cholesterol pills.
It may be worth getting the foot pulsus checked by your doctor.
Foot pulsus
Detailed Answer:
Yes, you are right. Metformin can cause lactic acidosis. However it is rarely seen. It is more possible when there is kidney failure.
Good to hear that symptoms reduced after reducing Metformin dose. What dose are you on now?
Calcitriol is not Vitamin D. It is activated Vitamin D ( 1, 25 hydroxy vitamin D).
Exetrol is Ezetemibe and it rarely cause Myalgia unlike many other cholesterol pills.
It may be worth getting the foot pulsus checked by your doctor.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I am no longer on Metformin. I've been off it for over a year now. I am now on insulin (Lantis and Apidra).
16 months ago I had no foot pulses in either foot. This was the result of two checks - one by an endocrinologist and the other at the annual diabetes check. However after being on insulin for 18 months, during which time my HbA1c has been 42 (6.0) or below (down to 37, or 5.5), my foot pulses had returned, although they were weak during the last check two months ago.
In terms of your comment about Calcitriol, do you have any recommendations about vitamin D? Also, could there be some sort of vitamin B (eg, B12) deficiency?
16 months ago I had no foot pulses in either foot. This was the result of two checks - one by an endocrinologist and the other at the annual diabetes check. However after being on insulin for 18 months, during which time my HbA1c has been 42 (6.0) or below (down to 37, or 5.5), my foot pulses had returned, although they were weak during the last check two months ago.
In terms of your comment about Calcitriol, do you have any recommendations about vitamin D? Also, could there be some sort of vitamin B (eg, B12) deficiency?
Brief Answer:
Arterial doppler scan
Detailed Answer:
Okay. Thank you for sharing those details.
Infact, what you feel as " Muscle pain" could be claudication pain due to reduced blood supply to leg. You may conform this by doing an arterial Doppler scan of leg blood vessels.
Calcitriol ( 1, 25 hydroxy vitamin D) is activated vitamin D. In fact, this activation requires presence of PTH hormone from parathyroid. In people with low PTH hormone, vitamin D supplementation alone may not be enough as the conversion may not take place. That is the reason we give 1, 25 Vitamin D ( Calcitriol).
However, vitamin D ( not activated Vitamin D) per se is said to have so many independent effects on muscles etc apart from it's actions through 1, 25 hydroxy vitamin D. In that regard, it may be worthwhile checking the Vitamin D (total) level and supplement it if the levels are low. THERE IS HUGE DEBATE ON THIS AND YOU MUST DISCUSS WITH YOUR ENDOCRINOLOGIST regarding local policies.
Vitamin B12 deficiency is quite common in Diabetes patients. This is especially true when one use Metformin of 1000 mg and above.
Having said all these, my first priority in your case would be to rule out blockage in blood vessels causing Claudication pain. A leg arterial Doppler scan will help
Arterial doppler scan
Detailed Answer:
Okay. Thank you for sharing those details.
Infact, what you feel as " Muscle pain" could be claudication pain due to reduced blood supply to leg. You may conform this by doing an arterial Doppler scan of leg blood vessels.
Calcitriol ( 1, 25 hydroxy vitamin D) is activated vitamin D. In fact, this activation requires presence of PTH hormone from parathyroid. In people with low PTH hormone, vitamin D supplementation alone may not be enough as the conversion may not take place. That is the reason we give 1, 25 Vitamin D ( Calcitriol).
However, vitamin D ( not activated Vitamin D) per se is said to have so many independent effects on muscles etc apart from it's actions through 1, 25 hydroxy vitamin D. In that regard, it may be worthwhile checking the Vitamin D (total) level and supplement it if the levels are low. THERE IS HUGE DEBATE ON THIS AND YOU MUST DISCUSS WITH YOUR ENDOCRINOLOGIST regarding local policies.
Vitamin B12 deficiency is quite common in Diabetes patients. This is especially true when one use Metformin of 1000 mg and above.
Having said all these, my first priority in your case would be to rule out blockage in blood vessels causing Claudication pain. A leg arterial Doppler scan will help
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for that.
As far as everyday living goes, the leg muscle effect is nowhere near as bas as the tiredness, lethary, lack of energy and lack of motivation. This is my main concern. Any ideas about this?
As far as everyday living goes, the leg muscle effect is nowhere near as bas as the tiredness, lethary, lack of energy and lack of motivation. This is my main concern. Any ideas about this?
Brief Answer:
Few suggestions
Detailed Answer:
Okay, we need to consider causes of tiredness /lethargy and lack of energy. It could be physical causes or due to mental worries.
To rule out physical causes, you need to make sure that ur calcium, Thyroid and Blood glucose are normal and rule out anemia as well.. An ESR is worth doing at your age.
Make sure kidney and liver fuctions are normal. Rule out major vitamin deficiencies ( Vitamin B2 and Folic acid).
If all the above are okay and if a thorough physical examination is normal as well, we need to rule out anxiety or depression as a cause of your symptoms. Please do not get me wrong, but occult depression is a major cause of such symptoms.
Regards
Binu
Few suggestions
Detailed Answer:
Okay, we need to consider causes of tiredness /lethargy and lack of energy. It could be physical causes or due to mental worries.
To rule out physical causes, you need to make sure that ur calcium, Thyroid and Blood glucose are normal and rule out anemia as well.. An ESR is worth doing at your age.
Make sure kidney and liver fuctions are normal. Rule out major vitamin deficiencies ( Vitamin B2 and Folic acid).
If all the above are okay and if a thorough physical examination is normal as well, we need to rule out anxiety or depression as a cause of your symptoms. Please do not get me wrong, but occult depression is a major cause of such symptoms.
Regards
Binu
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Is an ESR a erythrocyte sedimentation rate?
According to my doctor my calcium and thyroid is okay. (However I do wonder if the test they do for thyroid is a really thorough one, so any suggestions you have would be REALLY helpful). Also, I have observed that my symptoms are significantly reduced when my blood sugars are in the 3.3 - 5.5 mmol/L range, but my diabetes nurse wants me to have higher blood sugars, to reduce the risk of hypoglycemia.
They regularly do kidney tests, and they come back okay, but I'm not sure about liver.
An interesting thing about depression is that I do tend to have a low-level depression if I have readings above 6.0 for more than 8 hours, but it disappears if my blood sugars get back down into the fives and below.
According to my doctor my calcium and thyroid is okay. (However I do wonder if the test they do for thyroid is a really thorough one, so any suggestions you have would be REALLY helpful). Also, I have observed that my symptoms are significantly reduced when my blood sugars are in the 3.3 - 5.5 mmol/L range, but my diabetes nurse wants me to have higher blood sugars, to reduce the risk of hypoglycemia.
They regularly do kidney tests, and they come back okay, but I'm not sure about liver.
An interesting thing about depression is that I do tend to have a low-level depression if I have readings above 6.0 for more than 8 hours, but it disappears if my blood sugars get back down into the fives and below.
Brief Answer:
Suggestions
Detailed Answer:
Sorry for the delay. Was stuck in hospital.
Yes, ESR is erythrocyte sedimentation rate.
The Thyroid function test which I recommend are TSH and Free T4 ( FT4). Please make sure that they are normal.
It is extremely dangerous to keep your blood glucose in the range of 3.5 . I do not recommend it and back your diabetes nurse's decision.
It is unusual for anyone to get depression just based on blood sugar readings alone. It may be a good idea to practice Yoga or meditation and an antidepressant pill. It will improve your mood and sense of well being.
Regards
Binu
Suggestions
Detailed Answer:
Sorry for the delay. Was stuck in hospital.
Yes, ESR is erythrocyte sedimentation rate.
The Thyroid function test which I recommend are TSH and Free T4 ( FT4). Please make sure that they are normal.
It is extremely dangerous to keep your blood glucose in the range of 3.5 . I do not recommend it and back your diabetes nurse's decision.
It is unusual for anyone to get depression just based on blood sugar readings alone. It may be a good idea to practice Yoga or meditation and an antidepressant pill. It will improve your mood and sense of well being.
Regards
Binu
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you very much for your answer.
I would like to note, though, that my 7-day, 14-day, 30-day and 90-day blood sugar readings (as of a few minutes ago) were all 5.6 mmol/L. This has meant I have had readings in the 2.9 to 10.1 range (but almost always between 4.0 and 7.0) in that time. It has been my observation that I have much more energy (and ability to function properly) in the 3.3 to 5.5 range. My HbA1c readings over the last two years have been between 42 (6.0) and 37 (5.5).
If you do have any other ideas about what may cause significant lack of energy, lethargy, tiredness and lack of motivation, please let me know.
I would like to note, though, that my 7-day, 14-day, 30-day and 90-day blood sugar readings (as of a few minutes ago) were all 5.6 mmol/L. This has meant I have had readings in the 2.9 to 10.1 range (but almost always between 4.0 and 7.0) in that time. It has been my observation that I have much more energy (and ability to function properly) in the 3.3 to 5.5 range. My HbA1c readings over the last two years have been between 42 (6.0) and 37 (5.5).
If you do have any other ideas about what may cause significant lack of energy, lethargy, tiredness and lack of motivation, please let me know.
Brief Answer:
Low blood sugars
Detailed Answer:
Hi,
As i mentioned earlier, very low blood glucose levels are dangerous. You must discuss with your diabetes nurse/endocrinologist about modifying the dose of insulins. Please Get a general physical examination done and blood works like CBC, ESR, electrolytes, TSH, Calcium etc. If they are normal, you should consider a low dose medicine to uplift your mood. This will help to improve your energy levels too.
Low blood sugars
Detailed Answer:
Hi,
As i mentioned earlier, very low blood glucose levels are dangerous. You must discuss with your diabetes nurse/endocrinologist about modifying the dose of insulins. Please Get a general physical examination done and blood works like CBC, ESR, electrolytes, TSH, Calcium etc. If they are normal, you should consider a low dose medicine to uplift your mood. This will help to improve your energy levels too.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
What do you define as "very low blood glucose levels"?
What would you recommend as an appropriate average blood sugar reading for a diabetic on insulin (assuming six readings a day: on waking, 2hrs after breakfast, before lunch, two hours after lunch, before dinner and two hours after dinner)?
What HbA1c should a diabetic on insulin aim for?
What would you recommend as an appropriate average blood sugar reading for a diabetic on insulin (assuming six readings a day: on waking, 2hrs after breakfast, before lunch, two hours after lunch, before dinner and two hours after dinner)?
What HbA1c should a diabetic on insulin aim for?
Brief Answer:
Different targets
Detailed Answer:
Good day,
Very good question.
Low sugars are below 4 mmol.
For an young person below 65 years, with out any heart or major diabetes complications, we aim for a very strict target of fasting glucose of between 80 to 100 mg/dl ( 4.4 mmol to 5.5 ) and post meal ( irrespective of breakfast, lunch or diner) glucose of less than 140 mg/dl ( 7.7 mmol). The Hba1c close to 6.5 %.
The same goals apply even for an elderly patient with no or minimal diabetes related complications.
However, for an elderly patient above 65 years, with cardiac problems or neuropathy or hypoglycemia unawareness ( no awareness of hypoglycemia), we want to keep the fasting glucose up to 130 mg/dl (7.2 mmol) and post meal glucose levels up to 180 mg/dl ( 10 mmol) and HbA1c between 7.5 to 8%.
There is a huge shift in diabetes management goals since 2011 when ESAD and ADA together published new guidelines on diabetes management guidelines. They advice patient specefic and tailor made management.
This means that doctors often decide targets differently for each person based on many factors. Hence a target for one person may not hold good for another person ( because each person is different)
Regards
Binu
Different targets
Detailed Answer:
Good day,
Very good question.
Low sugars are below 4 mmol.
For an young person below 65 years, with out any heart or major diabetes complications, we aim for a very strict target of fasting glucose of between 80 to 100 mg/dl ( 4.4 mmol to 5.5 ) and post meal ( irrespective of breakfast, lunch or diner) glucose of less than 140 mg/dl ( 7.7 mmol). The Hba1c close to 6.5 %.
The same goals apply even for an elderly patient with no or minimal diabetes related complications.
However, for an elderly patient above 65 years, with cardiac problems or neuropathy or hypoglycemia unawareness ( no awareness of hypoglycemia), we want to keep the fasting glucose up to 130 mg/dl (7.2 mmol) and post meal glucose levels up to 180 mg/dl ( 10 mmol) and HbA1c between 7.5 to 8%.
There is a huge shift in diabetes management goals since 2011 when ESAD and ADA together published new guidelines on diabetes management guidelines. They advice patient specefic and tailor made management.
This means that doctors often decide targets differently for each person based on many factors. Hence a target for one person may not hold good for another person ( because each person is different)
Regards
Binu
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
You mentioned a blood test CBC. What is that?
Brief Answer:
CBC
Detailed Answer:
Complete blood count. it is to assess blood counts and haemoglobin levels
CBC
Detailed Answer:
Complete blood count. it is to assess blood counts and haemoglobin levels
Note: For more information on hormonal imbalance symptoms or unmanaged diabetes with other comorbid conditions, get back to us & Consult with an Endocrinologist. Click here to book an appointment.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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