diabetes medicationsdiabetes medications and insurance companies •every insurance company has a...
TRANSCRIPT
Objective
Discuss New diabetes medications and their role in
treatment
Conflict of InterestI have no conflict of Interest
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Diabetes
• 40-50% of the US Population is expected to
develop Diabetes in their lifetime.
• If type 2 diabetes were a country it would be
the 3rd largest in the world.
• 90% of the tasks of diabetes management are
done at home by the patient – we better do a
good job of education. 3
Diabetes Medications and
Insurance Companies
• Every Insurance Company has a Formulary
• Tells you what medications they will pay for.
• And they all have this statement “this list of medications may change at any moment without warning or notice”.
• Be alert for the patient who has just changed insurance companies
• They usually don’t know what the new company (or their current insurance company) will pay for. Meters, test strips, meds, pumps, type of insulin.
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The 1st Line Treatment for
Diabetes
• Lifestyle changes• Decrease weight
• Recommend to lose 7-10% of current weight, if overweight
• Increase exercise
• Recommend 150 minutes per week
• Maintain the first two.
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DPP4-I, GLP-1
TZD
SGLT2-I
Metformin, TZDCycloset, GLP-1
Metformin, GLP-1
Metformin, GLP-1, Insulin, food
Insulin,GLP-1,
Sulfonylureas,
Meglitinides
Stimulates production of Insulin
Sulfonylurea
• Glipizide, Glyburide, Glimipride
• Glucotrol, Glynase, Diabeta, Micronase, Glucotrol XL,
• $4 / Month pill
• Low blood sugar
• Nausea / vomiting
• Hypoglycemia is the biggest concern.
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Insulin Sensitizer/Decreases
effect of Glucagon - Metformin
Biguanide• Glucophage, Glucophage XR, Fortamet, Riomet
• Decreases the liver’s glucose production – from inappropriate glucagon release
• Opens the cell and allows the body to use the insulin more efficiently – increases sensitivity.
• GI upset, diarrhea, gas - 30% of people will have this, of that 30% will have to stop the pill. Formulation change?
• Check the Creatinine >1.4 in women & >1.5 in men.
• Stop 24 hours before & after dye test. The most important is after the dye. 12 hour half life.
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Insulin Sensitizer - Metformin
• Use with caution in people with liver or kidney
problems.
• Take the pill with food to help decrease Gas and
decrease irritation to stomach.
• Used in PCOS to break the insulin resistance along
with lifestyle changes. .
• $4 / month pill
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Insulin Sensitizer -Thiazolidinedione
TZD
• Actos (Pioglitazone), Avandia (Rosiglitazone)
• Works at peripheral cells to help open the cells
and allow the body to use the insulin more
efficiently
• Watch for edema, weight gain (sodium shift)
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Insulin Sensitizer TZD’s
• Also may be used in PCOS.
• Might be effective in diabetes prevention
• Big controversy with Avandia so you won’t see this used much. It is on the market.
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Insulin Stimulator
Meglitinade Insulin Secretagogue
• Prandin (Repaglinide), Starlix (Nagletinide)
• Take at the beginning of each meal
• Works for 2 hours after taken
• Low blood sugar
• The problem with these pills is you have to take them at the beginning of the meal, since it works for 2 hours. People would forget.
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Alpha Glucosidase Inhibitor
• Precose, Glyset
• These drugs work in the intestines to slow the digestion of some carbs so that after meal blood sugar peaks are not so high.
• Take at the START of each meals
• GI upset, GAS, abdominal pain very common
• Hypoglycemia must be treated with pure glucose tabs, gel or milk as food absorption is delayed.
• You have to take this with the first bite of food –patients always forgot.
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DPP-4 Inhibitors
• Blocks the DPP4 enzyme so native GLP-s is not degraded, allows GLP-1 to stimulate insulin producation
• Does not interfere with any other medications or foods. This is an enzyme
• Caution using in patients with history of pancreatitis or medulary thyroid cancer
• New study found this has not happened.
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DPP-4
• Januvia (Sitagliptin)
• Onglyza (Saxagliptin)
• Tradgenta (Linagliptin)
• Nesina (Alogliptin)
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SGLT – 2 Inhibitor
• Normally the kidney
reabsorb glucose primarily
via SGLT2, sodium-glucose
co-transporter 2,
protein located in the proximal
tubule of the nephron.
• By inhibiting SGLT2,
these medications block
reabsorption of glucose thereby
increasing urinary glucose excretion.
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Selective Sodium-Glucose
Transporter
• The patient excretes more glucose through the kidneys out the urinary tract
• Will be glucosuria
• Patient may lose 300 calories/day, may decrease BP
• Side effects
• Vaginal infections,
• UTI
• Volume depletion19
SGLT – 2 Inhibitor
• Invokana (canagliflozin)
• Farxiga (dapagliflozin)
• Jardiance (empagliflozin)
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SGLT-2 Inhibitors and Kidney
Function
• Estimated Glomerular Filtration Rate/Kidney
Disease
• GFR > 60 – Great, no problem using the pills
• GFR 45 to 60 – Use the lower dose
• GFR < 45 – Avoid the meds (although some company’s
will say “use with caution” consider a safer alternative.
• If GFR down to 30’s need a nephrologist.
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Medications
Some pills are in combination
• ActoPlus Met – Actos and Metformin
• Avandamet – Avandia & Metformin
• Avandaryl - Avandia and Amaryl
• Duetact – Actos and Glimepiride
• Glucovance – Glyburide & Metformin
• Metaglip – Glipizide & Metformin
• Prandimet – Prandin and Metformin 22
Newer Combination Pills
• Janumet – Januvia and Metformin IR and ER
• Kombiglyze – Onglyza and Metformin ER
• Jentadueto – Tradjenta and Metformin
• Kazano – Alogliptin and Metformin
• Oseni – Alogliptin and Metformin
• Invokamet – Invokana and Metformin
• Xigduo XR – Farxiga and Metformin ER
• Glyxambi – Jardiance and Tradjenta 23
Amylin Symlin
• Symlin – (Pramlintide)
• Amylin is a hormone made in the beta cells.
• Amylin deficiency can make it harder to control glucose levels after meals.
• Reduces fluctuations of blood sugar
• Used with type 1 or 2 at every meal.
• Must eat 250 calories or 30 grams of carbs
• Watch for hypoglycemia
• Problem: Cost and so many shots24
Glucose Like Peptide – 1
GLP-1
• Replaces the GLP-1 hormone that is not being made or used. Responsible for the “incretin effect” 50-70% of insulin release with a meal
• Decreases glucagon release
• Slows gastric emptying
• “Satiety” hormone, helps people feel full faster
• People feel full longer, decrease food intake
• Nausea – transient, or with high fat meal25
GLP-1 - Replaces/Enhances
GLP-1
• Byetta (Exenatide) -Twice a day (2005)
• Victoza (Liraglutide) - Once a day
• Bydureon (Exenatide XR) - Once a week
• Tanzeum (Albiglatide) - Once a week
• Trulicity (Dulaglutide) - Once a week
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Cost of Insulin
• Sometimes this is the barrier for patients
• Insulin can cost $435 or more/vial
• NPH / Regular / Reli-On Brand cost $25-35/vial
• Sometimes skipping medications is cost related –
always ask them.
• Patient Assistant Programs
• Use of Free or Reduced Drug Cards
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Medications - Insulin
• Insulin is divided into four categories
1. Long Acting – Lantus, Levemir
2. Intermediate Acting – NPH (cloudy insulin)
3. Short Acting - Regular
4. Very Short Acting – Humalog / Novolog / Apidera
• All Insulin is now made in laboratories, not from animals
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Rapid Acting
Humalog / Novolog / Apidra
• Onset 5 to 15 minutes.
• Given at the meal to “cover” the food at the
meal.
• Peak action is 1 hour.
• Duration is 2-3 hours.
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Inhaled Insulin Afrezza
• A rapid acting inhaled insulin
Inhaled powder delivered using a small, discreet and easy to use inhaler – looks like a whistle.
• Administer at the start of the meal.
• Afrezza disolves instantly upon inhalation to the deep lung and delivers to blood stream – OK to use if you have a cold, allergies. Lung clearance very good.
• Peak insulin levels are achieved within 12 to 15 minutes of administration, and decline to baseline by approximately 180 minutes.
• Must be used in combination with a long acting insulin.
• Must have Baseline Spirometry before starting this medication.32
Fast Acting
Regular
• Onset 30 minutes, so should be given 30 minutes before a meal.
• Peak action is 1 – 3 hours.
• Duration is 5 to 6 hours.
• Main uses • Patient with Gastroparesis
• Patient with 24 hour tube feedings
• IV Insulin – 5 minute half life
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Intermediate Acting
NPH
• Onset 1-1 ½ hours
• Peak is 6 – 10 hours
• Duration is 12 – 16 hours
• Generally given at breakfast and bedtime
• Cloudy insulin – Be sure to mix thoroughly.
• May be used in pregnancy – generally at HS to control early morning blood sugars.
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Long Acting
Lantus (Glargine)/Levemir (Detemir)
• Onset in 1 – 1 ½ hours
• Duration is 24 hours
• Needs to be given at a consistent time
• Generally given at bedtime or morning
• Some may need twice a day shots
• May burn at the injection site
• Can Not be mixed with any other insulin
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New
Toujeo (Lantus) U300
• The large insulin molecule (lantus) is shrunk to a
smaller molecule so you have smaller surface area
which releases more consistently
• 1/3 Less volume
• 6 hours to reach peak (if there is a peak)
• 5 days to steady state
• More consistent duration of 24-36 hours – should
not need BID dosing. 36
When to give the Long Acting
Insulin
• At Bedtime
• If there is a peak, it will peak early morning.
• Many people have early morning high blood sugars.
• Judge if this is a good dose by the FBS
• At Breakfast
• If there is a peak it will peak in the evening
• May have a better weight loss with morning shot
• Check blood sugar before bed to determine if this is a good dose.
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Concentrated Insulin
• Regular U500 Insulin
• Is 5X more concentrated than insulin.
• 5 units of U500 is 25 units of U100 insulin
• Comes in 20 mL vials
• Generally given 3 times a day, with the three meals
• Try to spread the meals apart 6+ hours.
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Combination Insulin
• 70/30 – 70% NPH & 30% Regular
• 75/25 – 75% NPH & 30% Humalog
• 50/50 – 50% NPH & 50% Humalog
• Novolog Mix 70/30 – 70% NPH & 30% Novolog
Insulin with the name Novolin or Humulin is usually NPH mixed with regular
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What may be new?
• IDegLira
• Injectable medication that combines Victoza and
an Ultralong acting Basal Insulin degludec (a 42
hour insulin).
• Brand name will be Xultophy
• Fixed dose of GLP-1 and Insulin.
• Cost expected to be high
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What may be new?
• Long Acting DPP4
• All DPP4’s last 24 hours, but they are working on
a once week version.
• Omarigliptin 25 mg, lowers Alc 0.71 mg in a 12
week study.
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FDA approved Liraglutide for Weight
Loss
• Liraglutide (Victoza) now called Saxenda has been
approved as a treatment for chronic weight management
along with reduced calorie diet and physical activity
• Saxenda is a GLP-1 and can not be used with any other
GLP-1.
• Victoza doses is 0.6, 1.2 or 1.8 mg and Saxenda is 3 mg
• Concern will be nausea
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Step wise approach to
Type 2 Treatment1. Lifestyle changes
2. Inititate Metformin (lower Alc by 1-2%)
3. If Alc > 7% after 3 months... (not in any order)
1. Add sulfonylurea (lower Alc by 1-2%)
2. TZD (lower Alc by 0.5 – 1.4%)
3. DPP4-I (lower Alc by 0.7-1.2%)
4. GLP-1 (lower Alc by 0.5 – 1%)
5. SGLT-2-I (lower Alc by 0.7-1.5%)
6. Basal insulin (lower Alc by 1.5%)
7. Mealtime (bolus) insulin (1 or more meals)43
Step wise approach to
Type 2 TreatmentDecision on what medications to use
Based on ADA/EASD Recommendations 2012
Individualized decisions based on 7 factors
Patient attitude and expected treatment effort
Hypoglycemia and other risks
Disease duration
Life expectancy
Comorbidities
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continued
Established vascular complications
Resources, support system
Every medication regimen should be specifically designed for
that person
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Questions
• Rebecca Newberry APRN MS CDE
Diabetes Education Center of the Midlands
Omaha, Nebraska 68124
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