DIABETIC MEDICATION UPDATES/INJECTABLE MEDICATIONS
Introduction
- Diabetes is disease resulting from an inability to use and/or produce insulin, a hormone made by the pancreas
- If the body cannot produce insulin (type 1 diabetes) or cannot use it properly (type 2 diabetes), blood glucose levels build up in the blood. Diabetes is diagnosed based on elevated blood glucose levels.
What is diabetes?
} Diabetes mellitus (DM) is a group of diseases
characterized by high levels of blood glucose resulting from defects in insulin
production, insulin action, or both.
} The term diabetes mellitus describes a metabolic
disorder of multiple aetiology characterized by chronic hyperglycaemia with
disturbances of carbohydrate, fat and protein metabolism resulting from defects
in insulin secretion, insulin action, or both.
} The effects of diabetes mellitus include long–term
damage, dysfunction and failure of various organs.
Types Of Diabetes
} Type 1 Diabetes Mellitus
} Type 2 Diabetes Mellitus
} Gestational Diabetes
} Other types:
} LADA (Latent Autoimmune Diabetes Of Adult)
} MODY (maturity-onset diabetes of youth)
} Secondary Diabetes Mellitus
The goal of diabetes management:
- To keep levels of blood glucose, blood pressure, and cholesterol as close to the normal range as possible.
- A major study, the Diabetes Control and Complications Trial (DCCT), sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), showed that keeping blood glucose levels close to normal reduces the risk of developing major complications of type 1 diabetes.
Management of diabetus mellitus:
- The major components of the treatment of diabetes are:
- Diet and Exercise
- Oral hypoglycaemic therapy
- Insulin Therapy
- Non insulin injectable medication
Non-insulin injectable
- Pramlintide (Symlin)
- Liraglutide (Victoza)
- Exenatide (Byetta)
- Exenatide ER (Bydureon)
- Dulaglutide (Trulicity)
1. Pramlintide (Symlin)
- What it is: It's a man-made version of a hormone called amylin, which your pancreas makes along with insulin when your blood sugar levels rise.
- Who can take it: It's approved for people with type 1 diabetes who are taking insulin. It's also OK'd for people with type 2 diabetes who are taking insulin, a sulfonylurea drug, or metformin. If you think you could get pregnant, tell your doctor, since researchers haven't studied this drug in pregnant women.
- What it does: You take pramlintide with insulin after a meal. The two drugs work together to lower your blood sugar. Pramlintide also helps you digest food more slowly. This puts less sugar into your bloodstream. In addition to controlling your A1C levels, pramlintide helps lessen your appetite, so you eat less.
- Side effects: Nausea is the most common side effect. Starting this drug at a low dose and increasing it slowly can help fight this side effect. Others include less appetite, vomiting, stomach pain, tiredness, dizziness, or indigestion.The drug can also cause low blood sugar if you don't adjust the amount of insulin you're taking.
2. Liraglutide
(Victoza)/ Albiglutide (Tanzeum)
- What it is: This is another GLP-1 drug. You inject it once a day. It helps your body release more insulin. This helps move glucose from your bloodstream into your cells.
- Who can take it: Adults who have type 2 diabetes but haven’t had results with other treatment. You take it in combination with metformin or a sulfonylurea drug. If you're planning to get pregnant, talk with your doctor. Liraglutide hasn’t been studied in pregnant women.
- What it does: Like the other GLP-1 drugs, liraglutide cues your pancreas to release insulin. This moves glucose out of your bloodstream and into your cells. It also limits how much of the hormone glucagon your body makes. This substance prompts your liver to release stored sugar. The drug also slows digestion.
- Side effects: The most common side effects include nausea, diarrhea, and headache. Inflammation of the pancreas (pancreatitis), which may be severe, is another side effect.
- All GLP-1 drugs, including liraglutide, have a boxed warning noting that in animal studies, this type of drug has been linked to thyroid cancer in some rats and mice. Experts don't know whether it has the same effect in people.
- It's possible to have an allergic reaction to liraglutide, or to get low blood sugar while you're taking it. If you get dehydrated from nausea, vomiting, or diarrhea, that could lead to kidney failure.
3. Exenatide (Byetta):
- What it is:Exenatide was the first GLP-1 drug approved by the FDA.Byetta came first. You take it as a shot twice daily. Bydureon is the newer, extended-release version, which you inject once a week. You can't take both drugs.
- Who can take it: Adults with type 2 diabetes for whom other treatment hasn't worked. If you think you might get pregnant, talk to your doctor. Researchers haven't studied this drug in pregnant women.
- What it does: Like other GLP-1 drugs, exenatide tells your pancreas to release insulin, which moves glucose out of your bloodstream and into your cells. It also limits how much glucagon your body makes. This hormone prompts your liver to release stored sugar. The drug slows digestion, too.
- Side effects: The most common ones include nausea, vomiting, diarrhea, feeling jittery, dizziness, headache, acid stomach, constipation, and weakness. These usually go away after the first month of treatment. Inflammation of the pancreas (pancreatitis), which may be severe, is another side effect.
§ The
FDA has also received reports of kidney failure in people taking this drug. All
GLP-1 drugs, including both types of exenatide, have a boxed warning noting
that in animal studies, this type of drug has been linked to thyroid cancer in
some rats and mice. Experts don't know whether it has the same effect in
people. It's possible you could get low blood sugar or have an
allergic reaction to the drug.
4. Exenatide Extended Release:
- Exenatide extended release (brand name Bydureon) is taken as single weekly dose along with diet and exercise to control blood glucose in type 2 diabetes. It helps the pancreas to make insulin while decreasing glucose release from the liver when blood glucose are high. It also slows digestion and keeps individuals feeling full longer and decreases appetite. As with standard exenatide, there is an increased risk of hypoglycemia when used in combination with Sulfonylureas. This medication is not a substitute for insulin, should not be used in patients withtype 1 diabetes or diabetic ketoacidosis, and is not recommended to be used with insulin.
5. Dulaglutide (Trulicity):
- What it is: This is another GLP-1 drug. Unlike the others, you inject it only once a week. It helps your body release more insulin and move glucose from your bloodstream into your cells.
- Who can take it: Adults with type 2 diabetes who have not had success with other diabetes treatment. You can take it alone, or in combination with metformin, pioglitazone, or a sulfonylurea drug. If you're planning to get pregnant, tell your doctor, since researchers haven't studied this drug in pregnant women.
- What it does: Like other GLP-1 drugs, dulaglutide prompts your pancreas to release insulin, which moves glucose out of your bloodstream and into your cells. It also limits how much of the hormone glucagon your body makes, since glucagon normally spurs your liver to release stored sugar. The drug slows digestion, too.
- Side effects: The most common side effects include nausea, vomiting, diarrhea, belly pain, and less appetite. All GLP-1 drugs, including dulaglutide, have a boxed warning noting that in animal studies, this type of drug has been linked to thyroid cancer in some rats and mice. Experts don't know whether it has the same effect in people.
Insulin Therapy:
Short-term use:
§ Acute illness, surgery, stress and emergencies
§ Pregnancy
§ Breast-feeding
§ Insulin may be used as initial therapy in type 2
diabetes
§ in marked hyperglycaemia
§ Severe metabolic decompensation (diabetic
ketoacidosis, hyperosmolar nonketotic coma, lactic acidosis, severe hypertriglyceridaemia)
Long-term use:
§ If targets have not been reached after optimal dose of
combination therapy or BIDS, consider change to multi-dose insulin therapy.
When initiating this,insulin secretagogues should be stopped and insulin
sensitisers e.g. Metformin or TZDs, can be continued.
INSULIN REGIMENS
§ The majority of patients
will require more than one daily injection if good glycaemic control is to be
achieved. However, a once-daily injection of an intermediate acting preparation
may be effectively used in some patients.
§ Twice-daily mixtures of
short- and intermediate-acting insulin is a commonly used regimen.
§ In some cases, a mixture of
short- and intermediate-acting insulin may be given in the morning. Further
doses of short-acting insulin are given before lunch and the evening meal and
an evening dose of intermediate-acting insulin is given at bedtime.
§ Other regimens based on the
same principles may be used
§ A regimen of multiple
injections of short-acting insulin before the main meals, with an appropriate
dose of an intermediate-acting insulin given at bedtime, may be used,
particularly when strict glycaemic control is mandatory.
Overview of Insulin and Action:
SOME EXAMPLES OF ORAL
MEDICATIONS USED FOR DIABETES?
1. Sulfonylureas
Stimulates the pancreas to release more insulin, both right after a meal and then over several hours
Stimulates the pancreas to release more insulin, both right after a meal and then over several hours
- Chlorpropamide (Diabinese)
- Glyburide (Micronase, Diabeta,Glynase PresTab)
- Glipizide (Glucotrol, Glucotrol XL)
- Glimepiride (Amaryl)
- Tolbutamide
- Acetohexamide
- Tolazamide (Tolinase)
2. Meglitinides and D-Phenylalanine
Derivatives
This type of pill helps
your body make more insulin for a short period of time right after meals. The
insulin helps keep your blood glucose from going too high after you eat, a common
problem in people with diabetes.
- Nateglinide (Starlix)
- Repaglinide (Prandin)
3. Biguanides
This type of medicine,
which comes in pill or liquid form, lowers the amount of glucose made by your
liver. Then your blood glucose levels don’t go too high. This type of medicine
also helps treat insulin resistance. With insulin resistance, your body doesn’t
use insulin the way it should. When your insulin works properly, your blood
glucose levels stay on target and your cells get the energy they need. This
type of medicine improves your cholesterol levels. It also may help you lose
weight. Cheap, well tested and often the first drug for doctors try.
- Metformin (Glucophage, Glucophage XR, Riomet, Fortamet, Glumetza)
- Alpha-Glucosidase Inhibitors
- Acarbose (Precose)
- Meglitol (Glyset)
4. DPP-4 Inhibitor
Improves insulin level
after a meal and lowers the amount of glucose made by your body.
- Sitagliptin (Januvia)
- Sitagliptin (Januvia)
5.Thiazolidinediones
(TZDs)
- This type of pill helps treat insulin resistance. With insulin resistance, your body doesn’t use insulin the way it should. Thiazolidinediones help your insulin work properly.
- Rosiglitazone (Avandia)
- Pioglitazone* (Actos)
6. Alpha-glucosidase
Inhibitors
- Slows down the digestion of foods high in carbohydrate, such as rice, potatoes, bread, milk, and fruit.
- Acarbose (Precose)
- Miglitol (Glyset)
7. Bile Acid
Sequestrants
A cholesterol
medication which can also help to lower blood glucose.
·
Colesevelam (Welchol)
8. Combination Pills
- Oral diabetes medications may also come in combination tablets such as
- Pioglitazone & metformin) (Actoplus Met)
- Glyburide & metformin (Glucovance)
- Glipizide & metformin (Metaglip)
- Sitagliptin & metformin (Janumet)
- Saxagliptin & metformin (kombiglyze )
- Repaglinide & metformin (Prandimet)
- Pioglitazone & glimepiride (Duetact)
- Rosiglitazone/ glimepiride (Avandaryl)
DIABETIC
DIET
Diet is a basic part of management in every case.
Treatment cannot be effective unless adequate attention is given to ensuring
appropriate nutrition.
Dietary treatment should aim at:
§ ensuring weight control
§ providing nutritional requirements
§ allowing good glycaemic control with blood glucose
levels as close to normal as possible
§ correcting any associated blood lipid abnormalities
The following principles are recommended as dietary
guidelines for people with diabetes:
§ Dietary fat should provide 25-35% of total intake
of calories but saturated fat intake should not exceed 10% of total energy.
Cholesterol consumption should be restricted and limited to 300 mg or less
daily.
§ Protein intake can range between 10-15% total energy
(0.8-1 g/kg of desirable body weight). Requirements increase for children and
during pregnancy. Protein should be derived from both animal and vegetable
sources.
§ Carbohydrates provide 50-60% of total caloric
content of the diet. Carbohydrates should be complex and high in fibre.
§ Excessive salt intake is to be avoided. It should be
particularly restricted in people with hypertension and those with nephropathy.
EXERCISE
} Physical activity promotes weight reduction and
improves insulin sensitivity, thus lowering blood glucose levels.
} Together with dietary treatment, a programme of
regular physical activity and exercise should be considered for each person.
Such a programme must be tailored to the individual’s health status and
fitness.
} People should, however, be educated about the
potential risk of hypoglycaemia and how to avoid it.
