What’s New With Diabetes

Pharmacology?

New Cardiovascular Horizons

And Management of the Diabetic Foot &Wound Healing

Joy Pape RN BSN CDE WOCN CFCN

President, EnJOY Life! Health Consulting, LLC
What’s New With Diabetes
Pharmacology?

Since When?
 Treatment Options for Diabetes
Inhaled Insulin

DPP-4

GLP-1

Detemir

Pramilintide

Exenatide

Aspart

Glargine

Glinides

Glitazones

Lispro

Metformin

Human Insulin

Sulfonylurea

Animal Insulin

1922 1950 1982-1985 1995 1996 2001 2003 2005 2006 2007

GLP-1 = Glucagon-like peptide-1; DPP-4 = Dipeptidyl peptidase-4

Adapted from CME Program entitled “Interactive Discussion With the Experts on Incretins: Preserving Pancreatic Function in Diabetes” – release date 8/31/07 on Medscape.com
 What’s New With Diabetes
Pharmacology?
•A LOT!
•KNOWLEDGE
•Remember…
•Not all meds for diabetes are for blood glucose
•Diabetes “Pharmacology”is not just drugs-
Medical Nutrition Therapy
Physical Activity
Stress Management & More
 What’s New In Diabetes
Pharmacology?

One new pill this year-Janumet ®

• Januvia ® and metformin

One new controversy this year

• Avandia ®
 What’s New In Pharmacology?
Diabetes is a group of metabolic diseases
characterized by:
• Hyperglycemia resulting from defects in
insulin secretion, insulin action, or both
• Long term damage, dysfunction, and organ
failure associated with chronic hyperglycemia
 What’s New In Pharmacology?
What do you think of taking Insulin?
Do you have insulin resistance?
 What’s New In Pharmacology?

Type 1
INSULIN
Meal Planning-Physical Activity-etc

Type 2-Gestational
LIFESTYLE
Meal Planning-Physical Activity-Meds maybe-etc
 What’s New In Pharmacology?
 A=Hemoglobin A1c-Glucose
<6-7%
 B=Blood Pressure
<130/80mm/Hg
 C=Cholesterol
Diabetes-LDL
Low HDL/ HighTriglycerides-
Small Dense LDL
non-HDL <130
 What’s New In Pharmacology?

 How to choose-understand
 What to choose-understand
 What you need to know
 What your patient needs to know
 What’s New In Pharmacology?
Type 2 Diabetes
Orals
 How they work
 How to choose

 What’s New In Pharmacology?
Sulfonylureas-Pancreas
• Stimulate the pancreas to put out more insulin
• Need to be making insulin!
• Can cause hypoglycemia
• Can cause weight gain
• Before meals/with meals/doesn’t matter
• Diabeta ®,Micronase ®, Glynase ® -glyburide,
Glucotrol ®, XL-glipizide, Amaryl ® -glimiperide,
• OLD-acetohexamide, tolazamide, tolbutamide,
Diabenese ® -chlopropamide
 What’s New In Pharmacology?
Meglitinides-Pancreas
• Stimulate the pancreas to put out more insulin
• Shorter duration of action
• Need to be making insulin!
• Can cause hypoglycemia
• Can cause weight gain
• Take one to thirty minutes before meals-
• Working? Check post-prandials
• Prandin ® -replaglinide, Starlix ® -nateglenide
 What’s New In Pharmacology?
Alpha-Glucosidase Inhibitors-Intestine
• Blocks the enzymes that absorbs starches in the small
intestine
• Does not cause hypoglycemia when taken alone-if
hypo-need to treat with pure glucose-glucose tabs/gels
• Doesn’t cause weight gain
• Take with the first bite of meal
• GI side effects-gas, bloating, diarrhea
• Do not take-IBD-Other GI-Cirrhosis
• Working? Check post-prandials-fastings
• Precose ® acarbose-Glyset ® -miglitol
 What’s New In Pharmacology?
Biguinides-Liver-muscles
• Decreases excess hepatic glucose production
• Increases insulin sensitivity-muscles
• Need to be making insulin!
• May improve lipid profile
• Does not cause weight gain-some weight loss
• Does not cause hypoglycemia when taken alone
• Side effects-GI-taste, flatulence, diarrhea
• Take after largest meal or break up
• Working? Check fastings
• Check Creatinine-Hold for certain procedures/surgery
• metformin-Glucophage, Glumetza, Riomet,Fortamet
 What’s New In Pharmacology?
Thiazolidindiones (TZDs)-Muscles-liver
• Improve insulin sensitivity-decreases hepatic glucose
output
• Other risks-benefits
• New black box warning for congestive heart failure
• Can improve fertility in some women-Birth Control
• Can be taken once or twice a day
• Can be taken with or without food
• Report edema, shortness of breath, other sx CHF
• LFTs -q 2 months for first year then periodically
• Avandia ® -Talk with prescriber-Don’t just stop
• Actos ® -pioglitazone, Avandia ® -rosiglitazone
 What’s New In Pharmacology?
DPP4-Inhibitors-
• Enzyme DPP4 blocks the message to pancreas to
release insulin, and to decrease hgp
• DPP4 inhibitors allow the message to get through
• Work in two ways
1-Increases insulin production from pancreas
2-Decreases hepatic glucose production hgp
• Working? Check post-prandials
• Weight stable-doesn’t cause hypo alone
• Januvia ® -sitagliptin
 What’s New In Pharmacology?
Combination Oral Meds
• Acto Plus Met® = Actos® & metformin
• Duetact® = Actos® & glimepiride
• Glucovance® = metformin & glyburide
• Avandamet® = Avandia® & metformin
• Avandaryl® = Avandia® & glimepiride
• Metaglip® = metformin & glipizide
• Janumet ® =Januvia ® & metformin
 What’s New In Pharmacology?
Incretin Mimetics-Replacement-Gut
• Incretin hormone mimics GLP-1
• Stimulate glucose dependent insulin release
• Suppresses hepatic glucose output by inhibiting
glucagon
• Inhibits gastric emptying
• Reduces food intake and body weight
• Enhances-beta cell proliferation in animals and
isolated human islets
• Peptide, so must be taken by injection
• Twice a day, up to one hour before 2 main meals-6hrs.
• Byetta ® -exenatide
 What’s New In Pharmacology?
Amylin-Replacement-Pancreas
• For type 1/type 2 who take insulin-lack amylin
• Insulin is (may be) only part of the story
• Reduces blood glucose variability and weight
• Reduces post-prandial blood glucose
• May need to take less insulin-50%, esp.at meals
• Taken within 15”before each meal (tid)
• Taken by injection-different syringe than insulin
• Main side effect is nausea-hypoglycemia
• Contraindicated-gastroparesis
• Symlin ® -pramlintide
 What’s New In Pharmacology?
Insulin-Replacement-Pancreas
 Insulin is a hormone made in your pancreas that allows
you to use the food you eat for energy
 Everyone needs insulin
 Some people make the right amount for normal blood
glucose
 Some people don’t make any, or very little-type 1 diabetes
 Some people make it- fight it-BG ok-insulin resistance
 Some people make it, can’t use it, have high blood sugar -
type 2
 Everyone needs insulin-it’s a good thing!
 What’s New In Pharmacology?
Insulin-Replacement-Pancreas
 Is needed for everyone who has type 1 diabetes!
 Is needed for many people who have type 2 diabetes
 Is needed when meal planning, physical activity, and pills
no longer get you to your blood glucose goals
 Is sometimes started later than it should be
 Should not be thought of as a threat
 Does not mean your diabetes is worse
 Does not mean you are doing anything wrong
 All insulins are not the same
 Can cause low blood sugar-take as much as needed for bs
 What’s New In Pharmacology?
Insulin-Replacement-Pancreas
What You Need to Know
 Different types of insulin
 What type of insulin you use
 How to take your insulin
 How to store your insulin
 How to prevent and treat a low
 How to dispose of sharps
 What’s New In Pharmacology?
Insulin-Replacement-Pancreas
• Type of Insulin-Onset, Peak, Duration
 What’s New In Pharmacology?
 Insulin – Administration
 What’s New In Pharmacology?

And if you still don’t know what to do…..

Meds?
Call your rep-pharmacist-Go to the internet….

Pump?
Ask your CDE, patient or family, and/or
Check the back of the pump for the 800# and Call!
 What’s New In Pharmacology?
Other
 Aspirin
The American Diabetes Association recommends 75-162 mg
per day for people with diabetes >40 years old
 Statins
 ACE-ARB
 Herbs/Supplements
Evidence Based
Unregulated system
May be effects-don’t forget the side effects
If it’s too good to be true, it’s probably isn’t true
There’s no magic pill, potion, or anything for diabetes
& weight loss
What’s New In Pharmacology?

Joy Pape RN BSN CDE WOCN CFCN

joy@joypape.com
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 Renal Protection
ACE-ARB

 Coagulation
Aspirin
 What’s New In Pharmacology?
Amylin-Replacement-Pancreas
• For type 1/type 2 who take insulin-lack amylin
• Insulin is (may be) only part of the story
• Reduces blood glucose variability and weight
• Reduces post-prandial blood glucose
• May need to take less insulin, esp.at meals
• Can cause lows with the use of insulin
• Taken before each meal (tid)
• Taken by injection
• Main side effect is nausea
• Symlin-pramlintide