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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
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Basic Information
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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
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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
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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
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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
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Now we are going to talk
about diabetes medications.
These medications
have been around
for awhile.
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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.
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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
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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
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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?
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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
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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 !
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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.
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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
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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
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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
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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.
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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.
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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.
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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).
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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)
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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.
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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.
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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
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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
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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
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Any questions
about pills +
before Insulin
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Insulin
Replaces what the body
can not make enough of
or does not use properly
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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.
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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.
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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.
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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.
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Any Questions
about Insulin
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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
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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.
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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.
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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.
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Stay Ready –
There are probably More Diabetes
Medications Coming
Any Questions
Thank you
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Thank you
Pam Wollenburg, APRN, CDE
CHI Health St Elizabeth
Diabetes Center
7441 O street, Suite 200
Lincoln, NE 68510
402-219-8777
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