Diabetes Medications March 12, 2016

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1 Innovative Approaches to Diabetes Care Diabetes Education Center of the Midlands Diabetes Medications March 12, 2016 Pam Wollenburg, APRN, CDE CHI Health St Elizabeth Diabetes Center Excellence in Diabetes 1 Lincoln, NE

2 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

3 Carbohydrates break down into sugars Basic Information Glucose stimulates the Pancreas to make Insulin The liver stores sugar to be used In times of stress Receptor Sites Insulin transports the glucose from the blood into the cells to be used for energy 3

4 What happens in Diabetes Type 2 Something plugs the receptor sites so the cells can not use the Insulin efficiently Type 1 Something Destroys the Cells that make Insulin. They Make Insulin, They just don t use it efficiently Receptor sites Plug up 4

5 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

6 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

7 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

8 Now we are going to talk about diabetes medications. These medications have been around for awhile. 8

9 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 insulin more efficiently. Does not cause Low Blood Sugars. 9

10 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

11 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

12 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

13 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 Not used much 13

14 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! Not Used Much Called the toot pill 14

15 These are the newest Medications. There are two types of medications that are hormones that are naturally made in the body. 15

16 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 Remember: Replacing or Enhancing 16

17 Dipeptide Peptidase-4 inhibitor DPP-4 Inhibitor Januvia Janumet Janumet XR Onglyza Kombiglyze XR Tradjenta Glyxambi Jentadueto Nesina Kazano Oseni sitagliptin sitagliptin and metformin sitagliptin and metformin extended release saxagliptin saxagliptin and metformin extended release linagliptin linagliptin and empagliflozin linagliptin and metformin alogliptin alogliptin and metformin alogliptin and pioglitazone 17

18 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

19 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

20 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

21 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 med 21

22 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

23 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

24 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

25 So, DPP-4 Hormone 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

26 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

27 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

28 Another New Pill SGLT-2 Inhibitor Sodium Glucose Linked Transporter-2 Inhibitor

29 SGLT-2 Medications Invokana (Canaglifozin) Invokamet (Canaglifozin / Metformin) Farxiga (Dapaglifozin) Xigduo XR (Dapagliflozin/Metformin XR) Jardiance (Empagliflozin) Synjardy (Empagliflozin & Metformin) 29

30 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

31 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 ~ 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

32 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

33 Combination Medications

34 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

35 Medications - Combinations Glyxambi Jardiance & Tradjenta SGLT2 & DPP4 Janumet Januvia & Metformin DPP-4 & Metformin Janumet XR Januvia & Metformin DPP-4 & Metformin XR 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

36 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

37 Any questions about pills + before Insulin 37

38 Insulin Replaces what the body can not make enough of or does not use properly 38

39 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.

40 Insulin Length in Hours of Action Times Tresbia 42 hours action Ultra Long Acting Toujeo U hours action Long Acting Lantus / Levemir hours action Long Acting NPH hours action Intermediate Acting Regular U500 Regular Humalog, Apidera Novolog, Humalog U hours action 5-6 hours action 2-3 hours action Intermediate Acting Fast Acting Rapid Acting

41 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

42 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 U

43 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

44 The Cost of these Medications Ridiculously Expensive A bottle of insulin is $350 to $450 Shop around for price Compare prices. NPH, Regular, 70/30 Insulin at Wal-Mart Reli-On is $25 to $35 for a vial. 44

45 Any Questions about Insulin 45

46 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

47 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

48 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

49 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

50 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

51 Stay Ready There are probably More Diabetes Medications Coming Any Questions Thank you 51

52 Thank you Pam Wollenburg, APRN, CDE CHI Health St Elizabeth Diabetes Center 7441 O street, Suite 200 Lincoln, NE pwollenburg@stez.org 52

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