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

Type 1 Diabetes Type 1  Usually diagnosed in children and young adults  People with type 1 diabetes do not make insulin Diabetes: Type 1. Online Image. Retrieved 20 July

Type 2 Diabetes  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 Diabetes: Type 2. Online Image. Retrieved 20 July

Diabetes Goals Fasting blood sugar goal: mg/dl Blood sugar 2 hours after starting a meal: Below 180mg/dl Bedtime blood sugar goal: mg/dl A1c goal: Less than 7% Abbott Diabetes Care. Online Image. Retreived 20 July

HbA1c Goals Importance of A1c. Online Image. Retrieved 07 July

Oral Medications

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.

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

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

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 ®. Online Image. Retrieved 23 July

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

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)

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

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 ®

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

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%

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

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

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. Online Image. Retrieved 20 July

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

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

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

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

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

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. Online Image. Retrieved 07 July

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

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

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

Injectable Medications

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.

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. Online image. Retrieved 07 July 2007

Byetta ® Byetta. Online Image. Retrieved 07 July

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.

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

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

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

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. Online Image. Retrieved 20 July

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. accessed 07 July

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 ®

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

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

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.. Online Image. Retrieved 20 July

Insulin Myths 1. 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. 2. 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. 3. Insulin causes weight gain You may gain a few pounds, however, the benefits to insulin far outweigh the risk of weight gain.

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. Online Image. Retrieved 07 July

Insulin Summary Types of Insulin OnsetDurationExamples Rapid Acting1 to 30 minutes 2 to 6 hoursApidra ® Humalog ® Novolog ® Exubera ® Arx iDMS ® Short Acting30 minutes to 1 hour 6 to 8 hoursHumulin ® R Novolin ® R Intermediate Acting 1 to 4 hours16 to 24 hours Humulin ® N Novolin ® N Long Acting1 to 4 hours12 to 24 hours Lantus ® Levemir ®

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. Online Image. Retrieved 20 July

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

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

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 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 Humalog ® /Novolog ®

Humalog ® Should be injected 15 minutes before a meal, or immediately after a meal Novlog ® should be administered at the start of a meal, or within 5 to 10 minutes of the start of the meal May be injected SQ in the upper arm, thigh or abdomen Available in a vial or in a pen  There are 3 Humalog ® pens to choose from HumaPen® MEMOIR ™ HumaPen® LUXURA™ HD Prefilled Pen  There are 4 Novolog ® pens to choose from NovoPen ® Jr NovoPen ® 3 NovoPen ® 4 Novolog ® FlexPen ® Humalog ® /Novolog ®

This pen is designed for parents and caregivers of children Can provide doses in ½ unit increments from 1 to 30 units Humalog. Online Image. Retrieved 07 July

Only insulin pen available with a memory Records the date, time, and amount of insulin for your last 16 doses Humalog. Online Image. Retrieved 07 July

Prefilled pen Pocket size Simple to dial up Audible clicks No refrigeration needed after the first dose Humalog. Online Image. Retrieved 07 July

Novolog ® NovoPen ® Jr.  Designed for kids  Colorful  Able to dial ½ unit increments Novolog. Online Image. Retrieved 07 July

Novolog ® NovoPen® 3  Can dial up 2 to 70 units  Can dial backwards to correct a dose  Uses cartridges for refills  Store at room temp Novolog. Online Image. Retrieved 07 July

Novolog ® NovoPen ® 4  For use with Novolog ®, NovoRapid ®, or Levemir ®  End of dose click so you’ll know your insulin has all been delivered  Available in 2 colors-silver and blue  50% less force needed to inject the insulin Novolog. Online Image. Retrieved 07 July

Novolog ®  Prefilled disposable pen with 300 units  Can dial backwards if a mistake is made Novolog. Online Image. Retrieved 07 July

Exubera ® The first inhaled insulin Indicated for patients with type 1 or type 2 diabetes above the age of 18 Begins to work within 10 to 20 minutes Effects last for up to 6 hours Decreases A1c by up to 1.9% Exubera. Online Image. Retreived 07 July

Exubera ® If you use any other inhalers, be sure to use those before using your Exubera ® Administer dose 10 minutes before a meal Available in 1mg and 3mg blisters  Three 1mg blisters do NOT equal 3mg

Exubera ® Do Not use if you:  Smoke-you must be smoke free for at least 6 months  Have a lung disease (asthma, COPD, etc)  Pregnant or under the age of 18 Stored at room temperature No batteries needed You must have a lung function test prior to beginning treatment with Exubera ® Dry powder inhaler  You won’t feel the powder as you inhale

Exubera ® Exubera. Online Image. Retrieved 07 July

Exubera ® Exubera. Online Image. Retrieved 07 July

Exubera ® Once a foil blister is opened it needs to be used within 3 months Inhaler must be cleaned once a week  Do not place any components in the dishwasher Release unit must be replaced every 2 weeks  Reminder stickers are included in the kit Inhaler device should be replaced once a year

Exubera ® Potential Side effects  Shortness of breath  Chest pain  Hypoglycemia Monitoring your blood sugar regularly can help prevent this  Cough Tends to occur with minutes after use, but does decrease over time

AERx ® iDMS Soon to be released from Novo Nordisk ® Indicated for type 1 and type 2 diabetes A liquid inhalation Administered 30 minutes before meals Inhaler device records the date, time, and units of insulin administered

Short Acting Insulin’s Cover insulin needs for meals eaten within 30 to 60 minutes

Begins to work within a ½ hour Lasts for 6 to 8 hours Should be a clear solution  Discard if solution is not clear Injected SQ into the thigh, arm, buttock, or abdomen Do not inject cold insulin  Roll vial gently in hand first to warm and mix the insulin Humulin ® R / Novolin ® R

Typically this medication is injected 30 to 60 minutes before a meal This is usually given 2 to 4 times a day Humulin ® R / Novolin ® R

If mixing with another insulin, draw regular insulin into the syringe first Do not freeze  If insulin has frozen, discard Store unopened vials in the refrigerator  Upon opening, insulin may be stored at room temperature for 28 days Humulin ® R / Novolin ® R

Novolin ® R Novolin ® R Pen  Can be used with the pens featured under Novolog  Store in the refrigerator until ready to use  Store at room temperature once opened  Discard 28 days after initial use

Novolin ® R Novolin ® R innolet  Disposable  Large numbers  Audible clicks  Store refrigerated until ready to use  Store at room temperature once opened Insulin Devices. Online Image. Retrieved 07 July

Intermediate Acting Insulin’s Begins to work after a couple of hours, but can last for up to 24 hours.

Humulin ® N, Novolin ® N Indicated for type 1 or type 2 diabetes Begin to work in 1 to 2 hours Duration is 16 to 24 hours Store unopened vials and pen cartridges in refrigerator  If freezing occurs, discard insulin Store opened vials at room temperature for 28 days, and opened pen cartridges at room temperature for 14 days

Humulin ® N, Novolin ® N Usually administered 1 to 2 times daily Inject SQ into abdomen, buttocks, thigh, or upper arm  Solution should be clear, discard if not clear Do not inject cold insulin  Roll insulin vial in palm of hands to warm and mix before injecting May be used with a vial and syringe or in a pen If mixing with regular insulin, draw regular insulin into the syringe first

Long Acting Insulin’s Provide steady 24 hour blood sugar control. One Touch Ultra 2. Online Image. Retrieved 20 July 2007http://

Indicated for type 1 or type 2 diabetics  Not indicated for children under the age of 6 Onset of action is 1 to 2 hours Duration is 24 hours Dosed once daily at any time of day  Inject at the same time each day Do NOT mix with any other insulin

Store unopened vials in the refrigerator  If insulin freezes, discard Opened vials and pen cartridges may be stored at room temperature for 28 days  Available in vials for use with a syringe or in cartridges for use in a pen Injected SQ into thigh, arm, buttock, or abdomen Clear solution, if solution is not clear then discard

OptiClik® Pen:  Pen available FREE from your physician  Insulin cartridges available from your pharmacy  Digital dose display  Audible clicks  Doses from 1 unit to 80 units  Pen may also be used with Apidra ®

Added benefits of Lantus ®  Decreases A1c by up to 1.7%  Once a day injection  When used in combination with Metformin or a sulfonylurea, Lantus ® has been found to decrease free fatty acids which are linked to complications of diabetes such as insulin resistance

Indicated for type 1 or type 2 diabetics  Not indicated for children under the age of 6 Begins to work in 3 to 4 hours Store unopened in the refrigerator  Discard if insulin freezes  Once opened vials and pens are stable at room temperature for 42 days

Long acting insulin  Except at low doses-then it becomes an intermediate acting insulin Do not use in an insulin pump  May be used in a syringe or a pen Dosed once or twice a day  Once daily dose is given with the evening meal or at bedtime  Twice daily dosing is given in the morning and then 12 hours later

May be injected in the arm, thigh, buttock, or abdomen Solution should be clear  Discard insulin if solution is not clear Do not inject insulin cold  Roll vial in palm of hand to warm and mix solution

FlexPen ®  Disposable  Prefilled  Store at room temperature for up to 42 days  Do not store pen with needles attached Novolog. Online Image. Retrieved 07 July Levemir. Online Image. Retrieved 07 July

Hypoglycemia If your blood sugar gets to low, your brain can run out of “fuel”, this can cause serious complications if not treated.

Hypoglycemia Make sure your family & friends know what to do if your blood sugar gets to low. Signs/Symptoms:  Anxiety  Blurred vision  Feeling Cold  Feeling Weak  Drowsiness  Weak  Headache  Hunger  Sweating  Trembling  Unconscious

Hypoglycemia Treatment of hypoglycemia:  15g of Carbs, which include things like: Glucose tabs (3-4 or equivalent to 15g) 4oz fruit juice Frosting (equivalent to 15g) Meat & Cheese sandwich  Test your blood sugar 15 minutes later If still low repeat treatment options Recheck another 15 minutes later-if still low, contact your health care provider

GlucaGen ® Hypokit Small, compact Quick, easy to use Contains everything needed to increase your bloodsugar No medical training required for use Glucagen. Online Image. Retrieved 12 July

References Abbott Diabetes Care. Online Image. Retreived 20 July Accu Chek meter systems. Online Image. Retrieved 20 July chek.com/us/rewrite/content/en_US/2.1:10/article/ACCM_general_article_2353.htm Actos. Retrieved. 07 July Apidra. Retrieved 07 July Armstrong, L. Lacy, C., Goldman, M., Lance, L. (2007). Drug Information Handbook (15 th ed). Hudson, Oh: Lexi-Comp. Avandia. Retrieved 07 July Avandia in the News: Questions and Answers. Retrieved 15 July Bayer Health Care. Online Image. Retrieved 20 July Bellaire, S., Clauson P., Cramer J., Okikawa J. Compliance with inhaled insulin treatment using the AERx® iDMS insulin Diabetes Management system. Diabetes Tchnology and Therapeutics. 2004: Berkrot, Bill. Novo Nordisk’s liragulatide effective in Japan study. Reufers. 23 June Accessed 07 July Byetta. Retrieved 07 July Diabetes: Type 1. Online Image. Retrieved 20 July Diabetes: Type 2. Online Image. Retrieved 20 July Exubera. Retrieved 07 July FreeStyle Flash®. Online Image. Retrieved 23 July Galvus. Retrieved 07 July Glucagon. Retrieved 07 July

References continued Humalog. Retrieved 07 July Importance of A1c. Online Image. Retrieved 07 July Insulin. Online Image. Retrieved 20 July easy&dir=drug&page=insulin Insulin. accessed 15 July Insulin Devices. Retrieved 07 July Insulin Myths and Realities. accessed 15 July Januvia. Retrieved 07 July Lantus. Retrieved 07 July Levemir. Retrieved 07 July Liraglutide.. Retrieved 10 July Novolog. Retrieved 07 July One Touch Ultra 2. Online Image. Retrieved 20 July Prandin. Retrieved 15 July Starlix. Retrieved 15 July Symlin. Retrieved 07 July