Treatment of Diabetes: Medications and Patient Education...Treatment of Diabetes: Medications and Patient Education Confidential1 DOS CME Course 2011Oxtober 2010 Christine L. Ahrens,

1

Treatment of Diabetes: Medications and Patient Education

DOS CME Course 20111 Oxtober 20101Confidential

Christine L. Ahrens, Pharm.D.NeuroICU Clinical PharmacistDepartment of Pharmacy

© Cleveland Clinic 2011

Objectives

• Describe modalities of diabetes treatment

• Describe insulin injection, titration, counseling

• Describe mechanisms of lipid therapyp py

DOS CME Course 20112 DOS CME Course 2011

2

Modalities of DM treatment

Balance Nutrition

Weight Loss / Glycemic control

MedicationsIncreased Physical

Activity



3

ADA/EASD Treatment Tier 1


ADA/EASD Treatment Tier 2


4

Initiating medications

• When can I stop these?When can I stop these?

• Does this mean I’m sick?

• Will I need to go to insulin?

• What if I forget?

• Adherence– Can’t predict

– Educate & Anticipate


Biguanide: Metformin

• How does it work?– Decreasing the amount of sugar (glucose) your body produces

& improves insulin sensitivity

• What will I notice when taking this?• What will I notice when taking this?– Positive

– Lower fasting BS, no weight change, TC, TG, LDL decrease, A1C ↓1.5

– Negative– GI - *diarrhea (10-15%), N/V (7-26%), lactic acidosis (0.03 cases per

1000 patient-years of metformin therapy)

• How do I take this?– Twice daily with food (depends on dosage form)Twice daily with food (depends on dosage form)


5

Metformin Titration

• Very important to limit side effects 500mg 1-2 times per dayeffects

• Increase every 5-7 days if tolerated

• Step back if side effects continue

g p y

850-1000mg twice daily

Maximum effective doseMaximum effective dose 2000mg daily


Sulfonylureas

• How does it work?– Enhancing insulin secretion from beta-cells

• What will I notice when taking this?– Positive

– Lower fasting/Post-prandial BS A1C ↓ 1.5

– Negative– Weight gain (2kg), hypoglycemia

• How do I take this?– IR glipizide & glyburide: 30min before meals

– XL & glimeperide: with breakfast


6

Meglitindes: Nateglinide (Starlix®), Repaglinide (Prandin®)

• How does it work?– Enhance insulin secretion


– Lower post-prandial BS, A1C ↓1-1.5

– Negative– Hypoglycemia

• How do I take this?– 1-30 minutes before meals three times daily


Thiazolidinediones: Pioglitazone (Actos®), Rosiglitazone (Avandia®)

• How does it work?– PPRAγ modulator increases insulin sensitivity


– Decrease fasting BS, A1C ↓0.5-1.4

– Negative– Weight gain, peripheral edema, lipid effects, HF, CVD?

• How do I take this?– Once daily without regard to food

– Take up to 6-8 weeks for full effect


7

α-Glucosidase Inhibitors: Acarbose (Precose®), Miglitol (Glyset®)

• How does it work?– Slow carbohydrate absorption in intestine


– Decrease post-prandial BS, A1C ↓ 0.5-0.8

– Negative– Diarrhea (31%), Flatulence (74%), bloating

H d I t k thi ?• How do I take this?– With first bite of food three times daily


Incretins: exenatide, liraglutide , sitagliptin, saxagliptin

• How does it work?– Increased glucose-dependent insulin secretion

• What will I notice when taking this?What will I notice when taking this?– Positive

– Lower BS, A1C ↓0.5-1, weight loss (exenatide, liraglutide)/neutral, less hypoglycemia (sitagliptin, saxagliptin)

– Negative– Nausea, cost, injectable (exenatide, liraglutide)

• How do I take this?– Exenatide: Injected twice daily before meals– Liraglutide: Injected once dailyLiraglutide: Injected once daily– Sitagliptin/Saxagliptin: Orally once daily


8

Glucagon-Like Peptide-1 Agonists Updates/Key Points

• Exenatide (Byetta®)– Acute pancreatitis (6 reports to FDA)– Renal dysfunction and acute kidney injury

Label changed Contraindicated CrCl < 30 ml/min and ca tion if CrCl–Label changed: Contraindicated CrCl < 30 ml/min and caution if CrCl 30-50 ml/min

–Initiate at lower doses (5 mcg BID)

• Liraglutide (Victoza®)– Associated with thyroid C-cell tumors (animal data)– Acute pancreatitis

• AACE/ACE GLP-1 agonists preferred to DPP-4 inhibitors as add-on therapy to medications which decrease insulin resistance


DPP-4 inhibitors Updates/Key Points

• Sitagliptin (Januvia®)– Acute pancreatitis (> 80 case reports)

–Label changed to monitor patients for s/s of pancreatitis

– Increased hypoglycemia risk with insulin and insulinIncreased hypoglycemia risk with insulin and insulin secretagogues

• Saxagliptin (Onglyza®)– Similar to sitagliptin with QD dosing, renal warnings, and efficacy

– No reports of pancreatitis

– CYP 3A4 substrate

• May consider over GLP-1 agonists since oral therapy and less GI effects

16 DOS CME Course 2011

9

Insulin

• How does it work?– Body’s hormone that moves blood sugar into cells


– Decreased BS, A1C ↓ 1.5-2.5%

– Negative– Hypoglycemia, weight gain

• How do I take this?– Injected 1 – 4 times per day, with and without meals

– Basal vs. Bolus


Insulin Myths

• Needing insulin means you are failingg y g

• Having to take insulin means you are in bad shape

• Taking insulin is painful

• Once on insulin, you will always be on insulin

T ki i li li i f di b• Taking insulin means complications of diabetes


10

Injecting insulin

• Strength 100 units/mL

• N dl 29 32 G 5 12 7• Needles 29-32 G; 5-12.7 mm– Use new needle each time

• Stable at room temp 14-28 days

• Syringe / vial– 10 mL (1,000 units)– Needles 1/3cc, 1/2cc, 1cc, 2cc

• Pen/Cartridge– 3 mL (300 units)

• Injection sites


Types of Insulin

Basal Bolus

• Intermediate– NPH (Humulin/Novolin N)

• Long acting analog– Detemir (Levemir)

– Glargine (Lantus)

• Short acting– Regular (Humulin/Novolin R)

• Rapid acting analogs– Lispro (Humalog)

– Aspart (Novolog)

– Glulisine (Apidra)


11

Insulin actions


Titrating Insulin

Nathan et al.DIABETES CARE.2009;32:193


12

Hypoglycemia

• Symptoms: Confusion, Dizziness, Feeling shaky, y p , , g y,Hunger, Headaches, Irritability, Pounding heart, Pale skin, Sweating, Trembling, Weakness

• Test blood sugar If < 70 treat with 15 g CHO

• Check BS after 15 min repeat tx if needed

• Eat balanced meal/snack with in 1 hour


Glucometer / Home blood sugar monitoring

• Frequency / Timing– Fasting AM/PM Adjust basal insulin

– 2 hour post-prandial Adjust bolus insulin

• Control Solution

• Test strip coding

• Write for:Write for: – Meter, test strips, lancets, alcohol swabs


13

DOS CME Course 201125

Documents

Treatment of Diabetes: Medications and Patient Education...Treatment of Diabetes: Medications and Patient Education Confidential1 DOS CME Course 2011Oxtober 2010 Christine L. Ahrens,