Diabetes.Blog.com

1 - Hi Bill,
I'm currently using Actos, should I discuss with my doctor about stopping it?
Thanks,
John (Comment this)

2 - Avandia and Actos are both in the same class of medications, and thus there is a possibility that any side effect seen with one might occur with the other.

That said, the recent NEJM article (CLICK HERE) was specifically about Avandia, and the authors stated that Actos was different:

"The question as to whether the observed risks of rosiglitazone represent a "class effect" of thiazolidinediones must also be considered. Pioglitazone is a related agent also widely used to treat type 2 diabetes mellitus. However, unlike rosiglitazone, pioglitazone has been studied in a prospective, randomized trial of cardiovascular outcomes, called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE). The primary end point, a broad composite that included coronary and peripheral vascular events, showed a trend toward benefit from pioglitazone (hazard ratio, 0.90; P=0.095). A secondary end point consisting of myocardial infarction, stroke, and death from any cause showed a significant effect favoring pioglitazone (hazard ratio, 0.84; P=0.027). Notably, pioglitazone appears to have more favorable effects on lipids, particularly triglycerides, than does rosiglitazone."

Hope this helps! (Comment this)

3 - Regarding the latest FDA warning about the potential for increased risk of heart attacks when using Avandia:
CLICK HERE

Is there any information other than the rather sketchy media bulletin? I would like to get answers for the following questions:

1) Does Avandia increase the risk of a heart attack only when taking the drug or does the increased risk remain after you stop taking the drug? (examples of other drugs would include: Vioxx - increased risk of heart attack stopped when you quit taking the drug, versus Phenfen - apparently resulted in permanent heart valve damage, thus increase in risk continued)

2) The FDA bulletin reported that GlaxoSmithKline pooled analysis indicated that "short-term" treatment (defined as 6 months) suggested an increase of 30-40 percent for risk of a heart attack. What if you have taken Avandia for a longer period of time (in the past or still currently using)?

3) Has there been any preliminary identification of testing that may be able to indicate potential damage or increased risk conditions?

Hope someone has some answers. Thanks,
 (Comment this)

4 - I've been on Avandamet for over 2 years. I'm also concerned about the identified risk factors of avandia. Is there any change to the risks if you take it with metformin? Once again, the media raises concerns without any answers or any "proof" of the claims. (Comment this)

5 - I used Dr. Bill's link to go read the study for myself. It's long (so I skimmed parts of it) but not as hard to understand as many. If I am reading things correctly, the study gathered trials and reports from other studies to compare 15,550 people using Avandia to 12,283 people on other diabetes meds or nothing. Most had poorly controlled diabetes. 86 of the Avandia people had heart attacks, while 72 of the others did. 39 of the Avandia people died of heart-related problems vs. 22 of the other people. That's an increase, but it sure is a small number out of all those thousands. The risk doesn't sound huge or anything. Even the authors say the results were barely statistically significant (hardly better than chance). Mostly, they say it shows the need for more and better studies. I'm not saying that the increased risk isn't scary, but it sure seems like it is not time to panic yet. I'd recommend everyone read the study and draw their own conclusions. (Comment this)

6 - Mark in Missouri,

I have not seen any data to indicate that Avandia causes damage to the heart muscle itself. However, Avandia is known to cause edema in some cases, and in severe cases this can lead to congestive heart failure. So, right there you have a risk for cardiac arrest. Furthermore, Avandia is known to cause weight gain, which is another contributing factor to heart disease. Therefore, it doesn't surprise me that there is an increased risk of heart attack with Avandia. These risks are small, though, and must be compared to the risk of not treating the diabetes.

Ironically, most people were afraid of Avandia because of fear of liver damage (as with Rezulin).
 (Comment this)

7 - Hello all! It's getting to the point that we will be afraid to take a tylenol! I am on Actos, and even though it hasn't been linked to this recent study involving Avandia, I have been wanting to go off of it for the past year. My internist originially started me on the maximum dose of 45 mg...several months later, I decided I needed to have an endocrinologist oversee my Diabetes. The very first thing he did was cut back my Actos to 30 mg, and then 3 months, later to 15 mg. My next visit is on June 4, and I would love to try eliminating it totally. I have put on weight, and am having a terrible time losing any weight, even though I really watch what I eat. How frustrating! So whether Actos poses any threat to my cardio-vascular health, or not, I really want to get rid of it! My last A1C was 6.5, and I am willing to risk it going a bit higher, or following a more strict diet, if that means eliminating one drug. (Comment this)

8 - for what its worth I started on avandia when I was first diagnosed with diabetes and found that in the months I used it I gained a lot of water weight due to edema in my legs.
I then changed to actos which worked better than the avandia but still caused me to have edema and weight gain.
I did not start to loose weight untill I got off of the actos and started on byetta.

I now have ankle bones that I can see and shape to my calves again.

I am very glad I no longer use those drugs. If byetta had not been a choice I would have gone to insulin just to get off of them and the glipizide.

 (Comment this)

9 - Hi, I am T2 since 1995, on insulin since then because of Pregnancy/breastfeeding, now my pancreas doesn't work much at all. I was on actos and had extreme swelling and could hardly walk. It worked so well but I had to stop it. My doc put on avandia and now I am so scared. I worry about my heart any way because of diabetes and a family history...does any one know if glucophage would help me? I am very insulin resistant. I have gained a ton of weight since my diagnosis and CANNOT get rid of it. What about Byetta? Can that be used with insulin if you are a type 2? I am very confused and discouraged. God help us all. (Comment this)

10 - I've answered most of the various questions that readers have asked, at Avandia Questions.

Hope this helps!
 (Comment this)

11 - Tamara,
Doctors who now proscribe TZD's like Avandia (which clearly cause weight gain)rather than Byetta for their overweight T2 diabetic patients, unfortunately will probably not be moved by the additional evidence that Avandia causes heart disiease to switch to Byetta. Only the removal of TZDs from the market will cause such (mal)practioners to abandon TZDs for Byetta.

It is thought that cramming too much fat into each fat cell interferes with the ability of insulin to take glucose from the blood and deposit into the fat stores in the fat cells. That is why T2 diabetes is associated with obesity (although if the cause of the obesity was a deficiency of incretins such as GLP-1, the causality is not clear). TZDs like Avandia allow more glucose to be taken from the bloodstream and be deposited as fat stores in the fat cells. Possibly Avandia does this by promoting the growth of new juvenile fat cells which have not yet been filled to their limit with fat and thus can recieve more (just what obese people need, not!)

For an overwieght T2 diabetic, the decision process involved with taking a TZD like Avandia is like waking up in bed on a freezing winter morning with two problems: 1. you have to pee, and 2. its too cold to get out of bed. Taking Avandia is like addressing the 2 problems by peeing in bed rather that getting up to go to the bathroom. It gives some short term relief to both problems but ultimately puts you in a worse situation.
 (Comment this)

12 - I fired Actos it's a horrible medicine and I've known it all along.I stopped it Sunday now see my numbers higher already. But I'd rather go back on Lantus. Then take this weight gaining junk. I have more energy already too. This drug dragged me down.

FYI:

Dear Doctor

I am writing to inform you that I have discontinued the use of Actos for treatment of my Diabetes. My next appointment is not until August and I can’t wait till then to get off this brutal medicine. I’ve been dieting and exercising and not losing weight. I can only attribute it to Actos as all the reading I’ve done and from the countless others who denounce this medicine as a weight gaining drug. My own experience also shows that I lost 52 pounds while on Byetta before after you took me off Actos. We added it back several months ago and the weight gain went up although part of it was due to my diet. However, now with diet my weight is still stagnating or even up some. Below are my current medicines.

Byetta 10X 2 , Amyral 6mg Daily,Metformin 2000 MG ER, Nexuim 40 MG, Diovan 80/12.5, Tricor 145 Mg, Lipitor 20MG,Niacin, 500 Mg, Fish Oil 1200 MG x 3

Please call my Pharmacy Wal-Mart 770-591-9402 if you want to add anything to this. Please understand I REFUSE to take Actos it’s not an option. This drug is a bad one the evidence on the internet from other diabetics is overwhelming.
 (Comment this)

13 - tony depalma, Byetta 10X 2 , Amyral 6mg Daily,Metformin 2000 MG ER, Nexuim 40 MG, Diovan 80/12.5, Tricor 145 Mg, Lipitor 20MG,Niacin, 500 Mg, Fish Oil 1200 MG x 3,
Tony,
Besides weight gain, which seems to be one of the major complaints regarding Actos, could you elaborate on the other negative side effects. I'm concerned because I recently started using Actos.
I read that it actually helps against heart attacks and strokes, compared to Avandia.
So far it hasn't impacted my BS numbers, I don't want to get stuck on this stuff if it does more harm than good.
Thanks,
John (Comment this)

14 - My GP took me off of Avandia yesterday and put me on Actos. I have taken metformin and many others and have never been able to keep my blood sugar down. I have taken Prandin in 1mg after meals and then had crashes. Then I took 2mg before going to bed and still got up in the morning with 150-170. I have not been able to get my weight (or my stomach) down and I get really tired and sleepy when my blood sugar gets up past 140. The higher it goes the sleepier I get.
I have done everything they have told me because I don't want to taken insulin shots. So, if Actos is bad news, what can I do now...wait for the heart attack? (Comment this)

15 - tony depalma,

I have been on Avandia for at least 6 years (5 years at 8 mg and 4 mg since last August). I gained a little weight on Avandia, but I gained ALOT more weight on Lantus, so don't count on Lantus to save you in the weight gain department. My complaint with Avandia has been the Edema, which I had quite noticeably in my ankles on the 8 mg of Avandia. It is less pronounced on the 4 mg. Similarly some joint pains I had had in my knee and shoulder and fingers has diminished after decreasing the Avandia. For these reasons, and possibly for weight gain, I, too, would like to drop the Avandia. I would not mind injecting a bit more Lantus to make up for it.

 (Comment this)

16 - Giovanni,

I think it makes me feel very sluggish. could be my imagination but I do know that the weight gain is enough to make it intolerable. (Comment this)

17 - James in MA, T2 1998; Byetta 5mcg 4/07, 10mcg 5/07; Lantus 10/04, (Novolog 5/05-4/07), Metformin 3x850mg, Avandia 4 mg. ,

Yes, I gained on lantus too so wish to stay away. Right now I am injecting Novalog when my numbers get to high after eating etc. I'm hoping getting off Actos will help me lose weight as I did before when getting off of it and Lantus and onto Byetta the miracle injection. I agree though it's best to not use any insulin. My Doctor upped the Amyral when I fired Actos. (Comment this)

18 - My endo put me on Avandia last year and I have had lots of problem with swollen ankles and legs. When I went to see him in April I took pictures of my fat ankles. I asked him if I should stop taking the Avandia and he said "no". But, now, with the further reports about heart trouble, I really don't want to take it. I called him yesterday and he was supposed to call me back, but hasn't. Now, it will probably be Tuesday before I can talk to him. But, I run out of Avandia tomorrow and I don't want to order 3 more months of it because it's expensive and I really don't want to take it. So, I guess I'll just skip a few days and see what happens. (Comment this)

19 - I have a great endo who is over 70. Really old fashioned "sit, talk, explain everything kind of doc". In March he gave me the ultimatum, byetta or insulin, A1c stuck at 8 or so. A year ago he told me how Actos/Avandia worked, just as Lance did in his post here. He pointed out that I had a nice Actos belly, some fluid retention, was gaining weight, and complained of feeling like crap. When my military pharmacy quit carrying Actos (probably because it is a Japanese drug) I switched to Avandia and felt even worse.

In March I started Byetta. Hail to the LIzard. for the first time in years I see numbers below 100. So I think my favorite Doc will understand that when the report came out I stopped the Avandia. Feeling better already I am, I am. Ankles are shrinking along with belly. Its been a week now and my numbers are actually improving. Other good things are happening also which I will report on later.
 (Comment this)

20 - Neal in FL, byetta 10mcg, metformin 2000mg, glyburide 5mg, , I have been on Avandia for over 1 year & feel terrible. My joints hurt all the time. My Dr. took me off of Avandia & put me on Januvia this week & hope to feel better soon. (Comment this)

21 - Jerry, I was on avandamet (with metformin) my dr. took me off and put me on metformin only. before, my hands were like ice(my hubby kept telling me to put my mittens on!) one day after stopping avandamet, my hands are nice and warm and I have much more peace of mind. (Comment this)

22 - what is byetta? how does it compare to metformin? new diabetic here-diagnosed with 354 in Nov. and an A1C of 11.5- three months later down to 110-124 with an A1C of 6.9 My Dr. is happy, but I was on avandamet-now just on metformin but wondering about this byetta i keep reading about-help! (Comment this)

23 - muffy,

There is a very active Byetta discussion forum. Look at the column to the right, #8, Current Discussion Forums at Diabetes.Blog.com, and #16, for Byetta Basics. (Comment this)

24 - Diane,
I have been on Avandia for 4 yrs, in the last 8 mos I've developed edema of my lower legs,ankles and feet. Today my Dr switched me to Actos, saying it did not cause edema. But after reading some of these entries as well as reading about Actos on the net, apparently it can. I wanted to ask you how the Byetta is working for you?

Sincerely, Darcy






DianeW in Washington, t2-2003, Byetta 10-2007, Metformin 850 X3, levemir, , (Comment this)

25 - Darcy,

Come over to the byetta island and I will have a comment for your ? there (Comment this)

26 - Bill the diabetesdoc, I have been on Avandia 8 mg for 4 yrs. IN the last 8 mos I've developed edema in my lower legs,ankles and feet. So my Dr switched me from maxide to lasix 40 and potassium for a month,this didn't touch the edema. So yesterday he took me off the avandia and switched me to Actos for a month, telling me that the actos, altho' in the same family as Avandia didn't cause water retention. The alternative was a new drug called Jenuvia, which hasn't been out for a yr yet. Do you have any suggestion? From what I've read, the Actos can also have the side effect of water retention. Please share your thoughts with me.

Darcy (Comment this)

27 - Darcy: I'm not Dr. Bill, but I just thought I'd mention that he has made a forum for Januvia, too. You can find it in column #8 to the right. You can ask questions there or just read past comments to learn more about this new med. (Comment this)

28 - Darcy,

I've not tried or had the experience of januvia but it would be better than the actos if you are still having the edema.

Anything else is better than the edema in my book! (Comment this)

29 - Plus its kind of silly to take another medication to counteract what one medication is causing with the edema.

I would think much better for your health to stop the medication that causes the edema in the first place than having another one added to counter its effects.

Lasix and other diuretics are hard on the kidneys and will up set your electrolyte balance.

I say ditch the actos! (Comment this)

30 - Darcy,

What other diabetes meds are you taking? (Certainly not only Avandia/Actos?) Januvia does not work the same way that Avandia/Actos do. It does not improve insulin resistance, but can help control bg by a similar mechanism to Byetta.

 (Comment this)

31 - No, I was only on Avandia until yesterday. It worked beautifully until 8 mos ago when the water retention began.


James in MA, T2 1998; Byetta 5mcg 4/07, 10mcg 5/07; Lantus 10/04, (Novolog 5/05-4/07), Metformin 3x850mg, Avandia 4 mg. , (Comment this)

32 - muffy,
Did you experience any problems with hair loss while on the advandmet? (Comment this)

33 - How often does Dr. Bill answer the questions on here? I am most anxious to see what he says to mine.

Darcy (Comment this)

34 - Darcy: Actually, he doesn't anymore - or at least very rarely. If he did, he would have time for nothing else. Basically, Dr. Bill established all these forums so people could share experiences with one another. He provides informational articles, monitors, troubleshoots, and pays for this huge site, which is a wonderful gift. But, on his home page, The Diabetes Monitor, he has a place where people can ask general interest questions. The link is up top, right before the beginning of "Comments". (Comment this)

35 - Darcy,

Only on Avandia? Wow, that is uncommon. Usually people are on a sulfonylurea and/or metformin together with Avandia, usually because people start with sulfonylureas (like Glyburide, etc.) when they get diagnosed.

 (Comment this)

36 - toneylee in va,

You mention some of the stats from the study including:
"the study gathered trials and reports from other studies to compare 15,550 people using Avandia to 12,283 people on other diabetes meds or nothing. Most had poorly controlled diabetes. 86 of the Avandia people had heart attacks, while 72 of the others did. 39 of the Avandia people died of heart-related problems vs. 22 of the other people."

Although these sound like small numbers they are based on meta-studies that are believed to be a reliable cross-segment of the population. The first part of the study (had heart attacks) had a statistical significance of .03, which is very statistically relavent. The second part of the study (heart related issues) was found to be statistically insignificant with a sig. of .06. Therefore, only the second part of the study is what the authors were referring to as being non-relevant.

Still very scary numbers. I plan on getting off Avandia as soon as I can get in to see my doctor. (Comment this)

37 - I quit taking Avandia on my own two weeks ago, and I am having lower numbers than I had while on it. Also, I don't have the swelling in my ankles. So, it looks like I don't need it. I take metformin 2000mg and Byetta 10. That seems to be controling it just fine. Betty in mo (Comment this)

38 - dennis, Don't be afraid of insulin, you can get more control faster with it and feel better overall (Comment this)

39 - Heya gang... doc this AM agreed that metformin is basically destroying me, so I am going to switch to Actos tomorrow morning and see how that goes. Even on 1000 mg a day metformin, I've been out sick once a week with these bouts of weakness and stupidity. Metformin's still doing great for my numbers: A1C, glucose, cholesterol all look way better. I just can't keep a job. Here's hoping... -Peace, Pteryxx (Comment this)

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41 - Hello, I am very concerned, I have read the warnig concerning the avandia. I have been taking Actos for at least 3 years, and last March 26, 2007, had a heart attack. My question is how much in common are these two medications. Now I am on , a larger number of heart medications. Is it possible that the heart attck was caused by the Actos? I give up, they give you med's to help your standard of living, but the fail to tell you, it could shorten your life. Bob Deschene bdeschene@comcast.net (Comment this)

42 - Puddlepyrate: See Dr. Bill's post #2 above. Apparently Actos, possibly unlike Avandia, may be heart protective. (Comment this)

43 - I take Actos 10mg. as an insulin sensitizer. If you follow this logic you will discover a novel non toxic effective sensitizer that complements or competes with Actos and Avandia.


Matthew J. Brady, University of Chicago, Department of Medicine, identifies IRS2 as a brier to insulin effectiveness. http://www.jci.org/cgi/content/full/114/7/886 See Figure 1 on the web page, it is a good illustration of insulin resistance.


Read “The Development of an Extract of Artemisia dracunculus L. for decreasing the insulin resistance associated with diabetes, from concept to clinic.David M. Ribnicky1, Alexander Poulev, Sithes Logendra1, William T. Cefalu, Zhong Q. Wang, Ilya Raskin Biotech Center, Cook College, Rutgers University, 59 Dudley Road, New Brunswick, NJ 08901-8520, USA2 Pennington Biomedical Research Center/ Louisiana State University, 6400 Perkins Road, Baton Rouge, LA 70808. http://raskin8500-226.rutgers.edu/~alexanderpoulev/GRC.pdf.


Review “Method for treating type 2 diabetes with an extract of Artemisia
US Patent Issued on May 17, 2005 US Patent 6350478.” http://www.google.com/patents?id=s80JAAAAEBAJ&dq=US+Patent+6350478


Trace this into the Human Genome “GeneCard for protein-coding IRS2 GC13M109204”
http://www.genecards.org/cgi-bin/carddisp.pl?gene=Irs2


You will believe that Tarragon the kitchen spice known as Artemisia dracunculus L. is a superb insulin sensitizer and a potential substitute for Actos and Avandia or a complementary second pathway for insulin sensitivity.
 (Comment this)

44 - Early on with Actos 15mg. Excellent BG numbers. No weight gain at all. No fluid retention noted. Time will tell, but so far, for ME Actos has been very effective. The latest tests that I have seen show that for those without a heart failure issue, Actos has a positive effect on lipid readings especially HDL levels. Very few (if any) drugs have a notable positive effect on HDL levels...so.. (Comment this)

45 - I'm not muffy, but I did experience hair loss when I started taking Avandia. My hair stylist asked me about this. We were noticing when we washed my hair, pieces were coming out in strands of 8-10 hairs at a time. The doctor didn't think Avandia was causing it, but said he would monitor it. As of 3-4 weeks, I asked the doctor to change my meds because of the hoopla about Avandia. His drug of choice for me was Actos. I found out two days later this drug was put on the black list also. This just makes me mad! I have been seeing a dietician for 7 months who has helped me achieve great BS levels (HA1C 6.2), however I just can't make the weight come off. She suggested I see their endocronologist who prescribes different meds - Byetta is one of them. She knows I have been working hard, and says she's had good results with her patients who didn't take Avandia or Actos. I met with the endocronologist today, and I am excited to know that there is a bit of hope to help me with my weight loss. I have been monitoring my diet daily during this time. Last week my calories ranged between 1,100, to 1,500. I am severely OBESE! (almost 300 pounds). I am so hoping the byetta will help me because I have been doing all I know to eat right and get this part under control. (Comment this)

46 - I took ActoPlusMet which is a combination of Actos 15mg with Metformin 850mg for over one year. During that time I gained over 20 pounds which is not that much but I always looked "swollen" in the face but had great bg numbers so kept taking it. Beginning of May, I asked my doctor to change the Actos to Januvia. I lost 7 pounds within a few days, then continued to lose a few more pounds without really making any diet or exercise changes. Last week the Januvia seemed to quit working- high bg numbers both fasting and postprandial and also had developed severe headache so Sunday I quit taking the Januvia. Figured I'd go back on Actos until I could see my doctor. Took Actos 3 days and on Tuesday when I came home from work my feet and ankles were extremely swollen. I didn't realize just how bad Actos was with fluid until then. Needless to say, I haven't taken anymore. I'm just taking the Metformin and also 2mg Amaryl which I had left over from past. I'm needle phobic but I don't think I have any choice but to consider either Byetta or some form of insulin. I've only been diagnosed diabetic for 3 years but seem to have progressed past meds really quick. I had hoped to be 10 years or more down the road before getting to point meds don't help. Of course, Actos helped the bg numbers but side affect just not worth it. I'm also very disappointed in the Januvia. Also regarding hair loss, I too am experiencing that. However, it actually started several months before my diabetes diagnosis so I think it's the diabetes itself in some way. Don't really know for sure (Comment this)

47 - Janice, Personally I would not have gone off of the Januvia after only 1 week of "highs". It could have been any number of things that has caused them, not the Januvia failing. Did you contact your dr before going off? Do you keep a food diary with food, exercise, and numbers recorded? Do you exercise? Going off of a med on your own isn't the best idea and I think it would be best if you contacted your dr. If you keep a food diary already go back and check if in the summer heat your eating patterns have changed, mine tend to during the summer and I have to be very careful. Have you stopped exercising because of the heat? Also have you increased your water intake because of the summer heat? (Comment this)

48 - It's become obvious that what works for one person may be a big problem for another, so genralized conclusions about meds and different foods seem foolhardy. Yes, certain risks are apparent for different meds, but the actual experience for each individual person varies greatly. So far, some 10 days into Actos, I have absolutely no weight gain and no notable fluid retention. What I do have a very good BG numbers. IF that continues, the fact that insulin resistance is my primary issue and Actos specifiacally targets that issue, makes Actos my drug of choice. Time will tell. I might add that SOME postulate that when insulin resistance is the primary priblem (often with early stage people)it results in overtaxing beta cells and that is what may cause further progression. One theory, but if true, that would may Actos a good way to possibly seriously inhibit long term progression in EARLY stage type II people. (Comment this)

49 - A crucial question remains...with hints of a positive answer in studies of Actos...IF you significantly reduce insulin resistance, does that stop/reverse deterioration of beta cells and can that halt progression? Is the initial insulin resistance causing the beta cells to deteriorate, or is more going on? Does early aggressive intervention against insulin resistance an important thing to do with long term benefits? Do we avoid meds as long as possible using only diet and exercise..or do we aggressively medicate to decrease resistance as early as possible and as much as possible in spite of low a1c numbers without meds but with diet and exercise alone? There lies a BIG unanswered question. Some early data indicates that Actos can have an effect on beta cell retention. Perhaps that is tied to its action against insulin resistance. Perhaps. So the metformin vs. Actos question is a difficult one to conclusively decide based upon known risk factors for each individual and the difference in their effectiveness in insulin resistance alone.

 (Comment this)

50 - Jim, Congrats on your success thus far. I hope it continues to be the same 6 mos down the road. I was on Avandia for over a year and the toxic side effects built up over time to where I was swollen with water weight and was having a hard time going up the stair case, couldn't breathe, at the rec center where I was lifting weights when the preceeding months I didn't have a problem. Now I have a friend who is on Actos, very thin, works out at the rec center too and she has not had a problem at all with Actos. We are all different as to which med works best for each individual.

I really hope you continue to be successful on Actos and make sure you include a good diet, exercise, and stress management into your lifestyle. Those will really help in the long run the most. (Comment this)