Medication Review Michelle Weddell Business Development Executive Clinical Specialist Podiatrist What is Diabetes? What is a type 1 diabetic? What is type 2 diabetic? Is there other forms of diabetes? Medications Oral Insulin New medications Lipid lowering medication & anti obesity drugs Blood pressure medication Anti platelet Circulation / Neuropathic pain drugs
Blood testing DCCT HbA1c -%% of blood glucose carried in the RBC over a 3 month period New measurement IFCC-HbA1c mmols /mol HbA1c : mean daily glucose HbA1C 12 11 10 9 8 7 6 5 4 Mmol/l 18 16 14 12 10 8 6 4 2 Sulphonureas Stimulate pancreas to make more insulin May help to make insulin more effectively used in the body Contra indications renal, liver, cardiac disease, pregnacy,, aggravation Side Effects Hypo s, stomach /bowel upsets, diarrhoea, headaches, weight gain
Gliclazide Diamicron -320mg Glibenclamide extra SE rash, tiredness, visual disturbance Avoid use in elderly Glimepiride Amaryl- 6mg od Gliquidone Glurenorm 180mg Tolbutamide 2g extra SE anaemia, jaundice, tinnitus, numbness Prandial Glucose Regulators Stimulate pancreas to produce more insulin Taken with meals Less risk of hypo s SE Abdominal pain, nausea, constipation, vomiting, diarrohea,, inc liver enzymes, weight gain, hypo s CI liver disease, pregnancy Drug interactions warfarin, antibacterial / antifungal drugs, simvastatin & contraceptive pill Repaglinide Novonorm 16mg
Alpha Glucosidase inhibitors Slows down absorption of starchy foods, Slows rise in blood sugars after meals SE Flatulence, diarrohea,, abdominal bloating / pain, liver disease CI GI disorders - inflam bowel disease, liver & renal disease, pregnancy DI drugs affecting GI movement, charcoal prevents effects of acarbose Acarbose Glucobay 600mg Biguanides Stops liver producing new glucose Overcomes insulin resistance by making insulin carry glucose to the muscle and fat cells Side Effects Nausea, Vomiting, diarrohea,, abdominal pain, loss of appetite, taste disturbance, lactic acidosis, red vit b12 absorption, Metformin Glucophage 3g
Thiazolidinediones glitazones Overcome insulin resistance Enables the body to use insulin more efficiently Pioglitazone Actos - 45mg Side Effects visual, upper respiratory tract infections, weight gain, ed, hypoaesthesia,, oedema, arthralgia, haematuria Thiazolideniones glitazones Rosiglitazone Avandia 8mg Side Effects Stomach / bowel upsets, anaemia, weight gain, hypercholestrolaemia, hyperlipidaemia, thrombocytapenia, dizzyness Can be used on their own or with metformin. CI cardiac failure, liver disease, pregnancy, DI other diabetic drugs, rifampicin- inc liver metabolism, Gemfibrozil dec liver metabolism Can be used in combination and triple therapy
Combination tablet Advandamet 2000mg Metformin and Rosiglitazone Competact 850mg Metformin & Pioglitazone Side effects as above Insulins how do they work https://www.diabetes.org.uk/upload/whole%20of%20testing%20and%20treating%202010%20%c2%adsingle %20pages.pdf https://www.diabetes.org.uk/onlineshop/livingwithdiabetes/ Insulins Rapid acting Analogue Injected 5-15 min before food Lasts 2 5hrs, use with long acting Novo Rapid / Humalog Long acting analogue Slowly absorbed Lasts about 24hrs Taken at bedtime Lantus Glargine Levemir - Detemir
Insulins Short Acting Soluble. Taken 15-30 mins before food. Lowers blood glucose quickly Peaks 2-6hrs, 2 can last 8 hours Humulin S Medium long acting Works slowly peaks 4-12 hrs cab last 8 30hrs Used in combination with short acting Humulin I, Insultard Insulins Mixtures Combine short and long acting Taken 15 30 mins beofre food Needs mixing Novomix30, Humalog mix 25 & 50 Mixatard30, 10,20,40,50 Delivery devices
Other Changes Exubera Inhaled Insulin withdrawn from the market. Byetta Exenatide Incretin mimetics. Injectable medicine that is used to improve blood glucose in type II diabetes. Produces right amount of insulin at right time Enhances insulin release Requires some βcell function Reduces weight Risk of hypo s s when given with sulphonylurea SE hypo s, nausea, injection sites reaction, adverse thyroid events, pancreatitis CI renal disease, GI disease, pregnancy, DI drugs that degrade in the stomach, antibiotics that need threshold concentrations, warfarin, statin,
Gliptins Sitagliptin and vilagliptin DPP4 inhibitors - inhibit action of the enzyme Increase insulin secretion, lower glucagon, reduce gastric emptying, inc satisfaction (fullness), reduce body weight. SE hypo s s when combined with a sulphonylurea CI moderate / severe renal disease, liver disease, cardiac disease, pregnancy DI other diabetic drugs, β blockers may mask hypo s Anti obesity Drugs Orlistat (Alli) xenical Available over the counter & prescription Reduces fat digestion 30% Also needs lifestyle changes Not recommended with acarbose caution with Metformin
SE oily stools, faecal urgency CI diseases of malabsorption breast feeding and pregnancy Precautions stops absorption of vitamins A,D,E &K Contraceptive pill Lipid modifying http://www.nice.org.uk/nicemedia/live/11982/40675/40675.pdf Cholesterol Pravastatin 10-40mg Atoravastatin 10-80mg Simvastatin 10-80 mg Reduces LDL and raises HDL Interacts with Erythromycin, Itraconazole, Warfarin.
Hypertension http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf Drugs Used to lower BP to <140/90 in patients over 50. If complications present then as low as possible ACE Inhibitors Lisinopril, Ramipril Angiotensin receptor blockers Losartan, candesartan, irbesartan Drugs Diuretics bendrofluazide, Frusemide Β Blockers atenolol, bisopropril, Propranolol, Calcium Channel Blockers Nifedipine, Amolodipine, Ditiazem Alpha blockers doxazosin Patients often require 3 or more Β blockers reduces mortality Post MI
Aspirin 75mg in patients > 50-1 prevention 2 in all patients Used with caution in people with uncontrolled BP Enteric coating reduces stomach problems Diabetic painful neuropathy Gabepentin Anti convulsant Only drug licensed upto 1800mg daily Amitripyline Anti depression More side effects drowsiness Taken at night 25-50mg Lyrica - Circulation Cilostazol (Pletal)) 100mg bd has been proven to increase walking when I.C present refer for vascular assessment and high risk team will request from GP / consultant if required