Medications for Diabetes

AGS Diab Med Brochure 4/18/03 3:43 PM Page 1 Medications for Diabetes An Older Adult s Guide to Safe Use of Diabetes Medications THE AGS FOUNDATION FOR HEALTH IN AGING

AGS Diab Med Brochure 4/18/03 3:43 PM Page 2 Over 16 million Americans of all races and ethnicities have diabetes and half of these people are over age 60. About 13% of people over the age of 70 years are known to have diabetes. Unfortunately, about 11% of all people between 60 and 74 years of age have diabetes but do not know it. Those most at risk for developing diabetes: are overweight have a family history of diabetes are African American, Latino, Pacific Islander, Asian American, or Native American have a history of diabetes during pregnancy (gestational diabetes), or have had a baby weighing more than nine pounds at birth Having diabetes can be scary, but there is a great deal that older adults can do to improve their health related to their diabetes. Learning how to care for one s own diabetes is very important. People with diabetes can decrease their chances of having a complication from diabetes by eating carefully, maintaining a healthy body weight, participating in regular exercise, not smoking, taking good care of their feet, and seeing their health care providers, including an eye doctor (ophthalmologist), regularly. You can ask your health care provider to refer you to a diabetes educator, a specialty physician, or a diabetes management program to help you learn more about diabetes care. Annual diabetes self-management training is covered under Medicare Part B. 2

AGS Diab Med Brochure 4/18/03 3:43 PM Page 3 Though many older adults can control their blood sugar (glucose) levels by eating the right foods and exercising, some also need to take medications to keep their blood sugar under control. People who have diabetes also need to be especially careful to keep their blood pressure and cholesterol under control; many older adults with diabetes need to use medication to do this. The AGS Foundation for Health in Aging has brochures available on Lifestyle Changes for Living with Diabetes, and the Complications of Diabetes in Older Persons. Contact information for the Foundation is listed on the back page of this brochure. 3

AGS Diab Med Brochure 4/18/03 3:43 PM Page 4 After considering the characteristics of your diabetes and your health in general, your health care provider should recommend a medication plan specifically for you. He or she should instruct you about the schedule for taking your medication(s), the timing of your medications and meals, and how to monitor your own blood sugar Monitoring blood sugar levels can be done with finger-sticks you do at home and/or blood tests done at the doctor s office. This guide will help you learn about prescription diabetes medications. The listing of medications that follows is designed to give brief information about and examples of commonly used medications that your health care provider can offer. Your health care provider and pharmacist will explain how the medications work and discuss any precautions or side effects with you. Any time you consider starting or stopping a medication, whether it is prescription or over-the-counter, always talk to your health care provider or pharmacist first. 4

AGS Diab Med Brochure 4/18/03 3:43 PM Page 5 Oral Medications (Pills) to Control Blood Sugar The pancreas produces a hormone called insulin. After we eat sugar, carbohydrates (starches), or other foods, insulin works to move blood sugar from our blood into our body cells. Body cells need the sugar to produce energy. Having diabetes means that your body either does not make enough insulin to keep moving sugar out of your blood into your cells, and/or your cells do not respond to the insulin in the usual way. In either case, the result is blood sugar levels that are too high. Every person should work closely with his or her health care provider to determine how much medication and what kind should be taken to control his or her blood sugar levels. There are five categories of oral medications (pills) to control blood sugar. Each category works through a different method of action in the body. Some people with diabetes take more than one oral medication and some also take insulin in addition to an oral medication. Taking too much of these medications can cause your blood sugar to go too low (hypoglycemia). All persons taking medications to lower 5

AGS Diab Med Brochure 4/18/03 3:43 PM Page 6 their blood sugar need to be aware of the symptoms of having blood sugar that is too low. Though each person is different, when your blood sugar is too low you might suddenly feel: hunger, dizziness, light-headedness, sweaty, fast heartbeat (palpitations), weakness or fatigue. When your sugar is too low you can make it higher by drinking some juice or eating some sugar candy. If these feelings do not stop you should call your doctor or other primary healthcare provider. Some older people with diabetes don t have these symptoms when their blood sugar is too low, which can make it more difficult for them to recognize a low blood sugar. Sulfonylureas Sulfonylureas have been used for decades. They cause the pancreas to produce more insulin, which causes blood sugar levels to go down. People who are allergic to sulfa drugs should avoid this medication. Sulfonylureas can cause low blood sugar and this can be life-threatening, so it is especially important that persons taking these medications know about the symptoms of low blood sugar (see above). Never take these medications if you are skipping a meal. Some people taking these medications also gain weight over time. The number of tablets a persons needs to take each day depends on the person s blood sugar levels and for how many hours the medicine works. Many sulfonylureas are available in a less-expensive generic form. Due to the especially high risk of low blood sugar, 6

AGS Diab Med Brochure 4/18/03 3:43 PM Page 7 chlorpropramide (Diabinese ) should never be taken by older adults. Generic Names Acetohexamide Chlorpropamide* Glimepiride Glipizide Glipizide extended release Glyburide Brand Names Dymelor Diabinese * Amaryl Glucotrol Glucotrol XL Diabeta, Glynase, Micronase Micronized glyburide Glynase Prestab Tolazamide Tolinase Tolbutamide Orinase *Should never be taken by an older adult. Alpha-Glucosidase Inhibitors These medications work by slowing the digestion of carbohydrates, which keeps the blood glucose from increasing too much after meals. They can be taken with insulin or other oral diabetic medications. Some people who take them lose weight, which can help improve blood sugar levels. These medications sometimes cause gastrointestinal side effects (diarrhea, gas, bloating). Generic Names Acarbose Miglitol Brand Names Precose Glyset 7

AGS Diab Med Brochure 4/18/03 3:43 PM Page 8 Biguanides Medications in this group work by decreasing the amount of glucose the liver produces and increasing the body s ability to use insulin. These medications can also lower blood cholesterol level, lower triglyceride levels, and lower LDL cholesterol (the bad kind). Some patients lose a few pounds when they start taking this type of medication, and this weight loss can help improve blood sugar levels as well. This medication can interact unfavorably with alcohol, so people who drink alcohol several times a week can become sick. In addition, people with certain kidney or liver problems should not take this medication. People taking this type of medication should have their kidney function checked regularly (at least once a year and after dose changes) using either a blood test or a combination of a blood test and a urine test. Some patients develop an anemia (disease of the blood) when taking these medications, so a blood test for this in the first few months of therapy is also a good idea. These medications can be taken with the sulphonylureas. Generic Names Metformin Metformin extended release Brand Names Glucophage Glucophage XR Meglitinides Meglitinides stimulate the pancreas to make more insulin. These are fast-acting medications, which 8

AGS Diab Med Brochure 4/18/03 3:43 PM Page 9 may allow some patients to vary the timing and quantity of their meals. These medications are relatively new and are not yet available as generics. Generic Names Nateglinide Repaglinide Brand Names Starlix Prandin Thiazolidinediones Thiazolidinediones work by helping the cells use insulin more effectively and move excess sugar from the blood into the cells for energy. These are the newest medications for diabetes. Both may cause swelling of feet or lower legs. People taking these medications should have liver function tests checked periodically by their health care provider. They are not yet available in generic form. Generic Names Pioglitazone Rosiglitazone Brand Names Actos Avandia Insulin Insulin is taken by injection or by using an insulin pump. Patients taking insulin must monitor their blood sugar levels by doing finger-stick checks regularly to make sure the sugar level does not become too low. There are several kinds of insulin that act differently. Each type of insulin is effective for certain lengths of 9

AGS Diab Med Brochure 4/18/03 3:43 PM Page 10 time. It is helpful for people taking insulin to know the following about their insulin treatment: the onset how long it takes before it starts to work peak effect when the insulin has the strongest effect duration how long the effect lasts With any kind of insulin, it is important to monitor blood sugar closely, take insulin at the right time, maintain a healthy diet and eat meals at regular intervals. As with some of the oral medications described above, if insulin is taken and a meal is not eaten at the right time, low blood sugar can result. Regular Insulin Regular insulin is a fast-acting insulin that takes effect in 30 minutes. Its peak effect occurs from 2-4 hours after injection and it lasts for 6-8 hours. 10

AGS Diab Med Brochure 4/18/03 3:43 PM Page 11 Very Fast Acting Insulin Humalog and Novolog are faster than regular insulin and lower blood glucose within 15 minutes. Patients must eat a meal 15 minutes after injection to avoid low blood sugar. These insulins are effective for 3-4 hours. Slower Acting Insulin Lente and NPH lower the blood glucose in 2-4 hours. Their peak effect is between 6 12 hours after injection and they last for 16-20 hours. Ultralente starts to lower blood glucose in 6-10 hours, peaks between 10-16 hours and last as long as 24 hours. Lantus starts working within 1 hour. It has a relatively constant action on blood sugar and has no peak effect over 24 hours. Lantus is given once a day at bedtime. Lantus should not be mixed together in a syringe with any other type of insulin. Combination Insulin Isophane insulin (NPH) combined with regular insulin (Novolin 70/30) takes effect in 30 minutes. 11

AGS Diab Med Brochure 4/18/03 3:43 PM Page 12 Peak effect occurs from 2 to 12 hours and lasts for 24 hours. Blood Pressure Medications Controlling your blood pressure can decrease your chances of having a heart attack or stroke. For some older adults with diabetes, it can be desirable to maintain a blood pressure that is even lower than the goal blood pressure aimed for in people without diabetes. However, you should always notify your health care provider if you are suffering from side effects from your medications, or if you feel often feel lightheaded, particularly when you stand up from a seated position. For many older adults with diabetes, a specific type of medicine called ACEinhibitors can be particularly beneficial. Talk with your health care provider about whether or not you should take an ACE-inhibitor. All older adults who take ACE-inhibitors or medications called diuretics (such as hydrochlorothiazide) should have their blood drawn regularly, and after dose changes, to monitor blood electrolytes and kidney function. 12

AGS Diab Med Brochure 4/18/03 3:44 PM Page 13 Cholesterol-lowering Medications People who have diabetes and have elevated cholesterol are at greater risk of having a heart attack. Persons with diabetes should have their cholesterol checked. If your LDL cholesterol is greater than 130 mg/dl, you should ask your health care provider about starting a medication to lower your cholesterol. The most common type of pill used to treat high cholesterol is a statin. Side effects include increased liver enzymes and muscle breakdown. Regular monitoring of liver enzymes by your health care provider is recommended for persons taking statins. The goal in people with diabetes is to get the LDL lower than 100mg/dL. Aspirin People with diabetes who take aspirin have a lower risk of dying from a heart attack. All older adults who have diabetes, and who are not on other blood-thinning (anticoagulant) therapy (such as coumadin) and who do not have another reason that they cannot tolerate aspirin, should take daily aspirin, 81-325 mg a day. Check with your health 13

AGS Diab Med Brochure 4/18/03 3:44 PM Page 14 care provider or pharmacist to be sure it is safe for you to do this. The Older Adult: Special Considerations 1. Most older adults have other medical conditions in addition to diabetes. Make sure your health care provider is aware of all illnesses, chronic conditions, allergies, or surgery that you ve had, and work with him or her to set goals for your diabetes care that make sense for you and your other health conditions. 2. Older adults with diabetes are at increased risk for drug side effects, especially as the number of medications a person takes increases. Keep an updated medication list and bring it with you every time you see your health care provider. Include every prescription medication and over the counter drug or health product that you take, including natural (herbal or homeopathic) medicines, with their dosages. Keep the list in your wallet or purse so it s available in an emergency. A medication diary is available from the FHA at www.healthinaging.org. 3. Use a medication box or other system to manage your daily medications. Ask your pharmacist for suggestions. 4. Use only one pharmacy for all your prescriptions. By having a complete record of all your 14

AGS Diab Med Brochure 4/18/03 3:44 PM Page 15 prescriptions, the pharmacist can alert you or your healthcare provider to possible interactions. 5. Be sure to report any side effects to your health care provider. Include how long they lasted, how severe they were, and what medications you were taking at the time. 6. Drinking alcohol is risky for older adults with diabetes. Talk with your health care provider about the risks of drinking alcohol when you are taking medications for diabetes. 7. Avoid smoking. Inhaling tobacco smoke, or breathing second-hand smoke, is bad for the health at any age, but it is especially deadly in older people with diabetes and/or heart disease. Plan to stop now your health provider can help you. 8. Discard outdated medications and those left over from prescriptions you no longer use. Old medications might lose their potency or might interact with medications you currently take. 15

AGS Diab Med Brochure 4/18/03 3:44 PM Page 16 The American Geriatrics Society The American Geriatrics Society (AGS) is dedicated to improving the health and well-being of older adults. With a membership of over 6,000 health care professionals, the AGS has a long history of improving health care for older adults. THE AGS FOUNDATION FOR HEALTH IN AGING The AGS Foundation for Health in Aging The AGS Foundation for Health in Aging (FHA) builds a bridge between the research and practice of geriatrics health care professionals and the public. FHA advocates on behalf of older adults and their special needs through public education, clinical research, and public policy. The AGS Foundation for Health in Aging The Empire State Building 350 Fifth Avenue, Suite 801 New York, New York 10118 1-800-563-4916 FAX 212-832-8646 www.healthinaging.org Source: California Healthcare Foundation/AGS Panel on Improving Care for Elders with Diabetes. Guideline for Improving the Care of the Older Person with Diabetes Mellitus. J Am Geriatr Soc 2003; 51:S265 S280