Diabetes Medications

1. Diabetes Medications An in-depth look at the medications used to treat diabetes

2. Type 1 Usually diagnosed in children and young adults People with type 1 diabetes do not make insulin Type 1 Diabetes Diabetes: Type 1. < http://www.medicinenet.com/script/main/art.asp?articlekey=42943 > Online Image. Retrieved 20 July 2007.

3. Most common type of diabetes People with type 2 diabetes do not make enough insulin or the insulin they make does not work very well Type 2 Diabetes Diabetes: Type 2. < http://www.medicinenet.com/script/main/art.asp?articlekey=42940 > Online Image. Retrieved 20 July 2007.

4. Diabetes Goals • Fasting blood sugar goal: 90-130mg/dl • Blood sugar 2 hours after starting a meal: Below 180mg/dl • Bedtime blood sugar goal: 100-140mg/dl • A1c goal: Less than 7% Abbott Diabetes Care. < http://www.abbottdiabetescare.com/adc_dotcom/url/content/en_US/20:20/product/Products_By_Category.htm > Online Image. Retreived 20 July 2007.

5. HbA1c Goals Importance of A1c. < http://www.apidra.com/a1c_glucose_control/Default.aspx > Online Image. Retrieved 07 July 2007.

6. Oral Medications

7. Biguanides Biguanides work by decreasing the amount of sugar produced by the liver. They also increase the ability for sugars to be absorbed by muscle and fat cells, and decrease the body’s ability to resist insulin.

8. Glucophage® (metformin) • Indicated for type 2 diabetes • Has been proven safe in children • Will not see any effect for a few days • Can take up to 2 weeks • Take with food to decrease GI side effects • Most common side effects are diarrhea, nausea/vomiting, flatulence, and lactic acidosis • If taking the once daily Metformin, take with your evening meal

9. Glucophage® (metformin) • If you have kidney problems, make sure your physician is aware of them • If you are having any kind of radiologic studies (CT scan, MRI, etc) stop taking your Glucophage® 72 hours before your test

10. Sulfonylureas These work by increasing insulin release from the pancreas, decreasing glucose output from the liver, and increasing the body’s sensitivity to insulin. FreeStyle Flash®. < http://www.abbottdiabetescare.com/content/en_US/20.10.10:10/product/Product_Profile_0002.htm > Online Image. Retrieved 23 July 2007.

11. glimepiride/glipizide/glyburide • Indicated for type 2 diabetes • Not approved for use in children • Begins to work within 15 minutes to 3 hours • If taking more than once a day • Take 30 minutes before meals • If dosed once a day • Take daily with breakfast • Do not take other medications within 2 hours of taking your sulfonylurea

12. glimepiride/glipizide/glyburide • Sulfonylurea’s are structurally similar to sulfa medications. If you are allergic to sulfa medications, make sure your doctor or pharmacist are aware of your allergy. • Common side effects include: • Sun sensitivity • Dizziness • Hypoglycemia • Headache • Nausea (Side effects such as headache and nausea will improve within 1 to 2 weeks of starting your medication)

13. Thiazolidinediones These medications work to decrease blood glucose by improving the cells response to insulin.

14. Recent news on Avandia® • Recent articles have focused on cardiovascular safety and Avandia® • If you have any type of heart disease speak with your doctor about the new information • Do not stop taking Avandia® without talking to your doctor first • GlaxoSmithKline (GSK) has full confidence in the safety of Avandia®, and at this time, Avandia® is not being removed from the market • The FDA is conducting further studies to ensure the safety of Avandia®

15. Avandia® /Actos® • Indicated for type 2 diabetes • Take once or twice daily • Take with or without food • Begins to work in 2 weeks, however, full effect may not be seen for 2 to 3 months

16. Avandia® /Actos® • If you have heart disease, make sure your doctor is aware • Have yearly eye exams and liver function tests • Found to decrease A1c by up to 1.4%

17. Avandia® /Actos® • Side effects: • Increased risk of bone fractures in women (typically hand, arm, ankle, and foot) • Increased risk of becoming pregnant if postmenopausal and still menstruating • Fluid retention • Edema

18. Avandia® /Actos® • Added Benefits of Actos® : • Decreases triglycerides • Improves HDL cholesterol • Disadvantages of Avandia® /Actos®: • Possible weight gain of up 2 to 6lbs • Slight increase in LDL cholesterol

19. Meglitinides These work to help the body release insulin at the start of each meal to help control mealtime blood sugar spikes Accu Chek meter systems. < http://www.accu-chek.com/us/rewrite/content/en_US/2.1:10/article/ACCM_general_article_2353.htm > Online Image. Retrieved 20 July 2007.

20. Indicated for type 2 diabetes • Take one tablet 30 minutes before each meal • Begins to work within 20 minutes • Effects last for up to 4 hours • May be taken alone or in combination with other diabetes medications • Most common side effects were hypoglycemia, joint aches, dizziness, and cold/flu symptoms

21. Store at room temperature • Do not take if you have liver disease • Do not take if you have type 1 diabetes

22. Alpha Glucosidase Inhibitors These medications slow the breakdown of carbohydrates in the intestine.

23. Precose® (acarbose)/ Glyset® (Miglitol ) • Indicated for type 2 diabetes • Not approved for use in children • Start this medication slowly. Gradually increase your dose to three times a day. • Take these medications with your first bite of your main meals • Do not take other medications within 2 hours of these medications

24. Precose® (acarbose)/ Glyset® (Miglitol ) • Have your liver enzymes checked every 3 months during your first year of treatment, then periodically • Adverse reactions include: • Hypoglycemia • Diarrhea • Abdominal pain • Flatulence

25. DDP-IV Inhibitors The newest class of diabetic medications. The pancreas gives the liver messages to make less sugar, while it makes more insulin. However, because of a substance in your blood called DDP-4, those messages do not make it through. DDP-IV inhibitors work by blocking the DDP-4 so that those important messages can get through. Januvia. < www.januvia.com > Online Image. Retrieved 07 July 2007.

26. Increases insulin when blood sugars are high • Reduces the amount of sugar made by your liver after you eat • Has been found to decrease A1C by up to 1.5% • Improves fasting and after meal blood glucose levels

27. Rarely causes hypoglycemia • Dosed once a day, with or without food • Has not been found to cause weight gain • Most common side effects: • Runny nose • Headache

28. Galvus® • Soon to be available from Novartis • Improves after meal blood glucose levels • Found to decrease A1C by 1-1.8% • When combined with Actos® it has been found to decrease A1C by up to 2.8% • Low risk of hypoglycemia • Dosed once a day • Side effects include headache, dizziness, and cold/flu symptoms

29. Injectable Medications

30. Incretin Mimetics These drugs mimic the incretin hormones found in your body. These drugs work by increasing your insulin secretion, increasing your beta cell growth/replication, slowing gastric emptying, and by decreasing your food intake.

31. Byetta® • Byetta® is NOT an insulin • Administer 60 minutes prior to morning and evening meals • Administer injection in the upper arm, thigh or abdomen • Take any other medications 1 hour prior to Byetta® because it may alter the ability of those medications to work Byetta. <www.byetta.com > Online image. Retrieved 07 July 2007

32. Byetta® Byetta. < www.byetta.com > Online Image. Retrieved 07 July 2007.

33. Byetta® • Before your pens first use, store it in the refrigerator, after you begin using your pen it may be stored at room temperature. • Discard your pen 30 days after initial use. • If your pen gets frozen, discard it. • Do not store your pen with the needles on it. This can cause air bubbles to form in the pen which can be dangerous.

34. Byetta® • May decrease A1c by up to 2.1% • May cause a weight loss of up to 11.2lbs • Most common side effect was nausea, which does decrease over time • Only indicated for type 2 diabetic patients

35. Byetta LAR • Expected to be released in 2008 • Once weekly version of Byetta® • Decreases fasting blood glucose levels by up to 50mg/dL, and decreases A1c by 2% • Most common side effect is nausea • Rarely found to cause hypoglycemia

36. Liraglutide • Brand name has not yet been released • Drug Expected to be released in 2008/2009 • Indicated for type 2 diabetics • Can be used alone or in combination with metformin or glimepiride • Once daily injection

37. Amylinomimetic When used in combination with insulin this class of medications will decrease after meal blood glucose levels by prolonging gastric emptying time, reducing after meal glucagon secretion, and by decreasing your appetite. Bayer Health Care. < http://www.bayercarediabetes.com/prodServ/products/contour/index.asp > Online Image. Retrieved 20 July 2007.

38. This is NOT an insulin • It does not replace your insulin, but it is used in combination with your insulin and therefore your insulin dose might be decreased • Do not use this if you have been diagnosed with gastroparesis • Monitor your blood sugar before and after meals while taking this medication • If your A1c level is above 9, this medication is not right for you Symlin. < www.symlin.com > accessed 07 July 2007.

39. Store unopened vials in the refrigerator. Once opened, the vial may be stored at room temperature. • Discard your vial 28 days after initial use • Administered as a SQ injection in the thigh or abdomen (do not inject into the arm) at least 2 inches away from a site where you injected insulin • Administer immediately prior to meals containing at least 30 grams of carbohydrates • Take other oral medications 1 hour before or 2 hours after you inject Symlin®

40. This can cause your blood sugar to drop to low (hypoglycemia). If this is going to occur, it will occur within 3 hours following your injection. • Monitor your blood sugar frequently to prevent hypoglycemia • Never mix Symlin® in the same syringe as insulin • The most common side effect is nausea

41. Benefits: • Fewer blood sugar “swings” throughout the day • You will feel fuller, so you will eat less, therefore possibly losing weight • You may not need as much insulin

42. Insulin Insulin is a hormone produced by the pancreas. It allows the body to use the sugar in food as a source of energy. When you have diabetes, often your body cannot produce its own insulin, so patients use man made insulin instead. Insulin. < http://health.howstuffworks.com/insulin.htm >. Online Image. Retrieved 20 July 2007.

43. Insulin Myths • Insulin should be a last resort for treatment • New guidelines suggest adding insulin earlier in treatment. Your A1c level should be your goal in determining your treatment plan. • Insulin injections are painful • You might be surprised at how small and thin the needle really is. Using an insulin pen can be even less painful. • Insulin causes weight gain • You may gain a few pounds, however, the benefits to insulin far outweigh the risk of weight gain.

44. Benefits to using Pen Insulin • No need to carry insulin vials and syringes • Pen contains the needle and insulin • Less painful • Pen has a smaller, thinner needle • Ensures the correct dose • Dial in the exact units. • Little preparation • Pens are fast, easy to use, and easy to store Novolog. < www.novolog.com > Online Image. Retrieved 07 July 2007.

45. Insulin Summary

46. Rapid Acting Insulin They work fast to manage mealtime blood sugar spikes. Rapid acting insulin’s act like insulin the body would make in a patient without diabetes. Insulin. < http://www.sawstonmedicalpractice.co.uk/display.php?location=Common%20drugs&title=Insulin&home=easy&dir=drug&page=insulin > Online Image. Retrieved 20 July 2007.

47. Apidra® • Indicated for type 1 or type 2 diabetics • Should be used in combination with a long acting insulin • This is a rapid acting insulin. • It begins to work within 1 to 2 minutes • It will last for 2 to 4 hours

48. Apidra® • Should be given 15 minutes before a meal or within 20 minutes of starting a meal • May be given via the OptiClik® injection pen, via an insulin pump, or with a vial and syringe. • May be injected into the thigh, abdomen, or upper arm • Should be clear in color, if not clear then discard

49. Humalog® /Novolog® • Indicated for type 1 or 2 diabetes • In type 1 diabetes it should be used in combination with a long acting insulin • In type 2 diabetes it should be used in combination with either a long acting insulin or an oral sulfonylurea • Will begin to work within 15 to 30 minutes and will last for 3 to 6 hours

50. Humalog® /Novolog® • Unopened insulin should be stored in the refrigerator • Once opened insulin may be stored at room temperature for 28 days • If placed in a pump, insulin should be replaced every 48 hours and cartridges should be replaced within 7 days