Diabetes MedicationsMarch 12, 2016

Pam Wollenburg, APRN, CDE

CHI Health St Elizabeth

Diabetes Center

Excellence in Diabetes

Lincoln, NE 1

Innovative Approaches to Diabetes CareDiabetes Education Center of the Midlands

My Goal today is

1. To talk about diabetes

medications

2. To talk about Insulin

3. To talk about the cost of

these medications

2

Basic Information

3

Glucose

stimulates

the Pancreas to

make Insulin

Carbohydrates

break down

into sugars

Insulin

transports the

glucose from

the blood

into the cells

to be used

for energy

The liver stores

sugar to be used

In times of

stress Receptor Sites

What happens in Diabetes

4

Type 1Something

Destroys the

Cells that make

Insulin.

Type 2Something plugs

the receptor sites

so the cells can

not use the

Insulin

efficiently

They Make Insulin,

They just don’t use

it efficiently Receptor sites

Plug up

How Diabetes Pills Work

1. Help the body use the insulin more

effectively/efficiently by opening the

receptor sites on the cells. Sensitizes

2. Stimulate the pancreas to make more

insulin. Stimulates

3. Increase glucose excretion from the

kidneys. Excrete Glucose

5

First Line Treatment

First Line Treatment is always

Lifestyle Changes.

Reduces the chance of diabetes by 58%.

Decrease weight

Recommend to lose 5-7% of current weight, if overweight

Increase exercise

Recommend 150 minutes per week

Maintain the first two

6

Second Line Treatment

Second Line treatment is Metformin.

Without lifestyle change, Metformin reduces the chance of Diabetes by 34%.

Lifestyle changes are more

effective than Medication

7

Now we are going to talk

about diabetes medications.

These medications

have been around

for awhile.

8

Metformin Sensitizer

Metformin, Metformin XR

Glucophage, Glucophage XR, Fortamet, Riomet

Decreases the liver from releasing extra sugar,

Improves insulin sensitivity by opening up the cells and allowing them to use the insulinmore efficiently.

Does not cause Low Blood Sugars.

9

Metformin

Side Effects.

Nausea and vomiting, diarrhea, and flatulence.

Abdominal discomfort, Weakness

Metformin should be held 24 hours

before and after any studies that

involve any dye

Has a very good cardiovascular

profile

10

Thiazolidinedione (TZD) Sensitizer

Actos (Pioglitazone), Avandia (Rosiglitazone)

Improves insulin sensitivity at peripheral sites and may affect HDL and LDL

Helps raise HDL (~15 points),

Not much LDL lowering affect – but may change the LDL to large particle.

Watch for edema – weight gain for no cause

May take up to 1-2 months for maximum affect

11

Insulin Stimulator Sulfonylurea

Glipizide, Glyburide and Glimipride

These stimulate the pancreas to release from the beta cells in the pancreas.

The main side effect of these drugs is hypoglycemia.

?Do they wear out the pancreas?

12

Meglitide Stimulates

Prandin (Repaglinide), Starlix (Nateglinide)

Take at beginning of each meal

Stimulates insulin production for 2 hours after pill taken

If forgotten, no need to take it later. Has to be at the meal.

Side effect – Low Blood sugar

13

Not

used

much

Alpha Glucosidase Inhibitor

Precose (Acarbose), Glyset (Migiltol)

Take with first bite of food

Many people forgot to take it.

Slows the digestion of carbs through the gut

GI upset, LOTS of Flatulance !

14

Not

Used

Much

Called the

“toot” pill

These are the newest

Medications.

There are two types of medications that are

hormones that are naturally made in the

body.

15

GLP-1 – Glucagon Like Peptide 1

These are shots.

Byetta (Exenetide) – 2x / day

Victoza (Lirglutide) – 1x/day

Bydureon (Exenetide XR) – 1x/week

(can take 7-12 weeks to work)

Tanzeum (Albiglatide) – 1x/week

Trulicity (Dulaglutide) – 1x/week

16

Remember:

Replacing or

Enhancing

Dipeptide Peptidase-4 inhibitor

DPP-4 Inhibitor

Januvia sitagliptin

Janumet sitagliptin and metformin

Janumet XR sitagliptin and metformin extended release

Onglyza saxagliptin

Kombiglyze XRsaxagliptin and metformin extended

release

Tradjenta linagliptin

Glyxambi linagliptin and empagliflozin

Jentadueto linagliptin and metformin

Nesina alogliptin

Kazano alogliptin and metformin

Oseni alogliptin and pioglitazone17

The Incretin Effect

Incretin hormones are found in the GI tract

(gut).

They cause an increase in insulin released

from beta cells after eating, but before the

blood glucose becomes elevated.

They inhibit glucagon released from the

pancreas

Especially during stress times

18

The Incretin Effect

Incretins slow the rate of absorption

of nutrients into the blood stream

by reducing gastric emptying

May directly reduce food intake.

You feel full faster and longer

Slows absorption of food so blood

sugar does not increase as fast.

May not feel like you need to

snack between meals

19

Then something happens…..

As type 2 diabetes develops, there may

be a weakening of the GLP-1 hormone

and blood glucose begins to increase.

The GLP-1 Hormone should

Increase in insulin production.

Slows the rate of absorption of food.

Reduces gastric emptying.

Inhibit glucagon release, especially during stress

time. 20

GLP-1 Receptor

Enhances the use of GLP-1

Helps your own GLP-1 work more efficiently

Must be glucose present to work, eat 250 cal/meal

Replaces the GLP-1 that is not being made

Slows gastric emptying

People feel full longer

May slow absorption of some meds.

May Decrease appetite.

Not a weight loss drug but many lose 10 to 15 pounds.

Nausea is a side effect.

Often tolerable, 30% take off med21

GLP-1 Cautions

Avoid using GLP-1

If there is a history or family history of pancreatitis

If there is a history of medullary thyroid cancer.

If patient has high triglycerides or alcohol problems

or other conditions that may cause pancreatitis.

If you have any kidney failure, talk to your

doctor before using this medication.

22

GLP-1 Caution

If you have any condition that slows the

digestion.

They slow gastric emptying even more.

If you are on Coumadin, monitor INR until

stable after starting on a GLP-1

May affect absorption of birth control pills /

antibiotics.

May cause low blood sugar if you are taking

certain pills or Insulin.

23

Diabetes Continues

As type 2 diabetes develops, and the GLP-1

hormone weakens, another hormone comes in

the picture.

DPP-4 hormone is always around and takes

advantage of the weakening GLP-1.

DPP-4 hormone rapidly deactivates the

GLP-1 hormone further.

24

DPP-4 Hormone So,

blood sugars start going up,

the person is hungrier all the time,

weight goes up,

decreasing activity, and

high blood sugars.

This is why it is so hard to lose weight as a person with type 2 diabetes.

A DPP-4 INHIBITOR was developed. 25

Dipeptide Peptidase-4 Inhibitor

DPP-4 inhibitors allows the GLP-1 to

work normally.

The mechanism of DPP-4 inhibitors

is to

increase incretin levels (GLP-1),

which inhibit glucagon release,

which in turn increases insulin

secretion,

decreases gastric emptying, and

decreases blood glucose levels.

“Prolongs the Incretin Effect”26

DPP-4 Inhibitors

Caution using in patients with a history of

pancreatitis or medullary thyroid cancer.

May cause severe joint pain.

This may start 1 day to years after starting the

medication.

After stopping the pill, symptoms relieved

within a month.

Monitor kidney function if using Sitagliptin (Januvia).

27

Another New Pill

SGLT-2 Inhibitor

Sodium Glucose Linked Transporter-2

Inhibitor

SGLT-2 Medications

Invokana (Canaglifozin)

Invokamet (Canaglifozin / Metformin)

Farxiga (Dapaglifozin)

Xigduo XR (Dapagliflozin/Metformin XR)

Jardiance (Empagliflozin)

Synjardy (Empagliflozin & Metformin)

29

Sodium Glucose Linked

Transporter – 2 Inhibitor

Normally the kidneys

reabsorb glucose primarily

via SGLT2, sodium-glucose

co-transporter 2.

By inhibiting SGLT-2, it

blocks reabsorption

of glucose thereby increasing

urinary glucose excretion.

30

SGLT – 2 Inhibitor

Causes you to excretes more glucose.

When you don’t have Diabetes, you excrete

glucose when the blood sugar is ~180 mg.

In Diabetes that threshold is moved to ~ 240 mg.

The SGLT-2 inhibitor moves the threshold to

~ 80-100 mg.

Many tell me when they first start the med,

they seem to go to the bathroom a lot, but as

the blood sugar comes down, this slows down.

31

SGLT – 2 Inhibitor

You can lose up to 300 calories / day.

To lose one pound you decrease 3500 calories.

Still need life style changes

Watch for dehydration, because you are losing fluid, be sure to drink plenty of water.

Biggest side effects:

Vaginal infections, Urinary Tract Infections

In uncircumcised male, genital infections

If it happens more than once, stop the med. 32

Combination

Medications

Medications - Combinations

ActoplusMet Actos & Metformin TZD & Metformin

Avandamet Avandia & Metformin TZD & Metformin

Avandaryl Avandia & Amaryl TZD & Sulfonylurea

Duetact Actos & Amaryl TZD & Sulfonylurea

Glucovance Glyburide & Metformin

Sulfonylurea & Metformin

34

Medications - Combinations

Glyxambi Jardiance & Tradjenta SGLT2 & DPP4

Janumet Januvia & Metformin DPP-4 & Metformin

Janumet XR Januvia & Metformin XR

DPP-4 & Metformin XR

Jentadueto Tradjenta & Metformin DPP-4 & Metformin

Kasano Nesina & Metformin DPP-4 & Metformin

Kombiglyze XR Onglyza & Metformin DPP-4 & Metformin

Invokamet Invokana & Metforman SGLT2 & Metformin

35

Medications - Combinations

Metaglip Glipizide & Metformin Sulfonylurea & Metformin

Prandimet Prandin and Metformin Sulfonylurea & Metformin

Oseni Nesina & Actos DPP-4 & TZD

Synjardy Jardiance & Metformin SGLT-2 & Metformin

Xigduo XR Farxiga & Metformin SGLT-2 & Metformin

36

Any questions

about pills +

before Insulin

37

Insulin

Replaces what the body

can not make enough of

or does not use properly

38

All Insulin does the same thing

Insulin’s job is lower the blood

sugar

The difference is:

How fast it does it

How long it works

There are many common things

about insulin:

Take the shot at the same time

every day.

Insulin Length in Hours of Action Times

Tresbia 42 hours action Ultra Long Acting

Toujeo U300 36 hours action Long Acting

Lantus /

Levemir

21-24 hours action Long Acting

NPH 12-16 hours action Intermediate Acting

Regular U500 10-12 hours

action

Intermediate Acting

Regular 5-6 hours

action

Fast Acting

Humalog,

Apidera

Novolog,

Humalog U200

2-3

hours

action

Rapid Acting

Common Insulin Guidelines

Insulin comes in Vials or Pens.

Some insulin is given once a day, some is

given twice a day.

Some insulin is given before every meal

Meal insulin – count carbs

Correction dose – based on blood sugar

Best if used just before the meal and at

regular times of the day.

41

Common Insulin Guidelines

All insulin is U100

Now it is coming in U200 and U300

This means ½ and 1/3 the volumne

Just less fluid,

The only exception is U500.

This is 5 times stronger than U100

5 units of U500 = 25 units of U100

ALWAYS TELL THE HEALTH CARE

PROVIDER YOU USE U500.

42

Common Insulin Guidelines

Always take it at about the same

time of day.

NPH is a cloudy insulin all the

others are clear. Be sure to MIX

NPH well.

Inhaled Insulin is a very rapid acting

insulin. Not sure if it is still on the

market.

43

The Cost of these Medications

Ridiculously Expensive

A bottle of insulin is $350 to $450

Shop around for price

www.needymeds.com

Compare prices.

NPH, Regular, 70/30 Insulin at Wal-Mart Reli-On

is $25 to $35 for a vial.

44

Any Questions

about Insulin

45

The Cost of these Medications

If you do not have insurance apply for the Patient Assistance Programs from the companies.

RxHope.com Look up PAP programs

Go to the medications web site and look for the PAP program.

Generally if you are on Medicare, Medicaid or a Federally Funded Program you can not use some of the coupons.

Look for the coupons and read who can use it. They are all different.

Many coupons for the pills can be used by Medicare, etc

46

The Cost of these Medications

Medicare in the Coverage Gap, who

are low income, can apply for PAP

for Insulin help.

Look up the forms

Look at the income guidelines.

If you are close, call and talk with

them.

47

The Cost of these Medications

Medicare/Coverage Gap – Start early.

You have to fill out Social Security Extra Help and be denied

You have to have proof you are in the coverage gap

You have to have proof you are low income (Income Tax Form)

You have to fill out the form and so does your provider.

Must be faxed from your provider’s office.

48

Insurance Formulary

Every insurance company has a prescription

“Formulary”.

Call the insurance company and ask for the

formulary or ask what medications are on the

formulary for high blood pressure.

Talk to your doctor about using one of them

Do that with every medication you are on and

look for discount coupons, vouchers. 49

Coupons

Whatever medication you are on,

Google the name of it.

Then look for any coupons or

vouchers

Do that with every medication you

are on and look for discount

coupons, vouchers.

Sometimes you can save a lot of

money, or get a few months free.

50

Stay Ready –

There are probably More Diabetes

Medications Coming

Any Questions

Thank you

51

Thank you

Pam Wollenburg, APRN, CDE

CHI Health St Elizabeth

Diabetes Center

7441 O street, Suite 200

Lincoln, NE 68510

402-219-8777

pwollenburg@stez.org

52