Your Guide to Diabetes Medications by

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									Your Guide to
Diabetes Medications
A supplement to Diabetes Dialogue, an official publication of the Canadian Diabetes Association

Spring 2007

      Your diabetes meds at work
          • Know your diabetes ABCs
          • Pharmacists on your healthcare team
          • Drug research: From test tube to you
Your medications and you

  By Arlene Kuntz BSP CDE

                        O N B E H A L F O F the Canadian Diabetes Association, Diabetes Dia-
                        logue is pleased to present the second annual consumer’s guide to
                        diabetes medications, your premier source for information about
                        the medications used to help manage your diabetes.
                            Diabetes management is a round-the-clock commitment –
                        whether you manage your type 1 diabetes with insulin, or whether
                        you manage your type 2 diabetes with lifestyle modification (includ-
  ing physical activity and nutrition) and/or insulin and medications.All of the medica-
  tions and insulins currently available in Canada that are used to manage diabetes are
  explained in detail here – with an explanation of how they work and why your doc-
  tor might prescribe them, along with important details about how they’re taken.
       You’ll also find a wealth of information on issues related to your medication man-
  agement, including:
  • optimal treatment targets: blood glucose, blood pressure and cholesterol (page 5);
  • why you may be prescribed more than one drug to manage your diabetes and its
     related complications (page 6);
  • a handy guide to all the medications used to manage your diabetes, with informa-
     tion about how they work, what you should know and their advantages (page 8);
  • pharmacists on your team: how they can help you manage your diabetes (page 13);
  • how a medication evolves, from concept in the lab to your drugstore’s dispensary
     (page 14).

  We hope you find your consumer’s guide to diabetes medications practical and use-
                                                                                                                                           PHOTO: BRITTANY ROSS

  ful, and we’d love to hear from you with any comments and suggestions you may have
  for future editions. Email us at

  We wish you good health and good reading!

  Arlene Kuntz is a pharmacist and Certified Diabetes Educator with Shoppers Drug Mart in Regina, SK. She is also
  Chair-elect of the Diabetes Educator Section of the Canadian Diabetes Association.

                                                                     Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007                 3
“Targeting” your efforts
  Reaching blood glucose, blood                                                     itoring and A1C tests are needed to provide a clear pic-
                                                                                    ture of overall blood glucose control.Your blood glucose
  pressure and cholesterol targets                                                  log can provide you with information about how treat-
                                                                                    ment may need to be adjusted to improve your A1C.
  is key to preventing complications
                                                                                    B is for blood pressure. The goal is 130/80 mm Hg
  BY CYNTHIA N. LANK                                                                or lower.All people with diabetes should have their blood
                                                                                    pressure measured at every diabetes-related doctor’s vis-
                C A N A D I A N D I A B E T E S A S S O C I AT I O N                it. Blood pressure control plays a key role in preventing

            reminds all people with diabetes to know their                          cardiovascular diseases such as heart attack and stroke,
            “ABCs” in order to reduce their risk of devel-                          as well as preventing diseases such as retinopathy (dam-
  oping the long-term complications of diabetes. At one                             age to the small vessels in the eye) and kidney disease.
  time, diabetes management focused primarily on blood
  glucose control.We now know that diabetes is a much                               C is for cholesterol. The primary goal is LDL choles-
  more complicated disease that requires a more compre-                             terol 2.0 mmol/L or lower. LDL cholesterol is common-
  hensive approach to treatment.When it comes to dia-                               ly called “bad” cholesterol, as it tends to deposit on the inside
  betes, ABC stands for the three key treatment targets:                            walls of blood vessels.The deposits are known as “plaque”
                                                                                    and over time can narrow the blood vessels and restrict
  A is for A1C. The A1C test is a simple blood test per-                            blood flow to different organs and tissues. If the plaque
  formed at the lab, which measures blood glucose con-                              bursts, blood will clot at the site of the plaque, and a heart
  trol over the previous 120 days.The goal is 7.0% or lower                         attack or stroke can result.All adults with diabetes should
  in most people, and 6.0% or lower in those in whom it                             have a blood test to measure their cholesterol at the time
  can be safely achieved. Chronically high blood glucose                            of diagnosis of diabetes and then at least once a year. In addi-
  levels harm the body’s small and large blood vessels and                          tion to measuring LDL cholesterol, HDL cholesterol
  nerves, and raise the risk of diabetes complications. In                          (“good” cholesterol), triglycerides and the ratio of HDL
  addition, high blood glucose negatively affects the body’s                        cholesterol to total cholesterol should also be measured.
  ability to fight infection. High blood glucose raises the                         These also provide information on cardiovascular risk.
  risk of every diabetes-related complication. All people
  with diabetes should have their A1C measured approx-                              S T U D I E S H AV E C O N C L U S I V E LY S H OW N that people
  imately every three months.The A1C test is not a sub-                             with diabetes can prevent the onset or slow the progres-
  stitute for self-monitoring of blood glucose, which                               sion of complications by meeting and maintaining the
  provides day-to-day information on how blood glucose                              above targets. For more information on how to reach these
  responds to food, medication and activity. Both self-mon-                         goals, see “Your diabetes medications at work,” page 6.

A supplement to Diabetes Dialogue, an official publication of the Canadian Diabetes Association

  Diabetes Dialogue                          Steve Kelman BSc MBA CFA             Photography                                For address changes, please
  Spring 2007                                Susan MacDonald                      Danijela Pruginic                          contact publisher.
  Volume 54, Number 1                        Teresa Schweitzer RN BScN CDE
                                                                                  Advertising                                General information
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  Diabetes Dialogue, the official pub-                                            Keith Communications Inc.                  about diabetes
  lication of the Canadian Diabetes          Clinical Advisor                     Telephone: (905) 278-6700                  Telephone: 1-800-BANTING
  Association, is published quarterly        Arlene Kuntz BSP CDE                                                            (226-8464)
  (Spring, Summer, Autumn,Winter).                                                                                           Email:
                                             Managing Editor                      Canadian Diabetes Association
  Its mission is to deliver current, reli-
                                             Fiona Hendry                         522 University Avenue, Suite 400           The appearance of advertising in
  able information about diabetes to
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  people affected by diabetes.               Assistant Editor
                                                                                  Tel: (416) 363-3373                        tute endorsement by the Canadi-
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                                                                                               Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007   5
Your diabetes medications at work
    Why your doctor may                                                            s   Blood glucose medications
                                                                                   A S P E O P L E W I T H T Y P E 1 D I A B E T E S cannot produce
    prescribe more than one                                                        their own insulin, they must take insulin every day, by
                                                                                   syringe, pen or pump.The recommended insulin regi-
    medication for your diabetes                                                   men for most people with type 1 diabetes is known as
                                                                                   a basal-bolus regimen, given by multiple daily injec-
    BY CYNTHIA N. LANK                                                             tions.This involves using intermediate- or long-acting
                                                                                   insulin (such as NPH, glargine or detemir) once or twice
          N M O S T P E O P L E W I T H D I A B E T E S , achieving and            a day, plus rapid-acting insulins (such as aspart, lispro

    I     maintaining blood glucose, blood pressure and cho-
          lesterol goals require treatment that combines
    lifestyle modification with medications.
                                                                                   or regular) at meals.
                                                                                       As type 2 diabetes involves both insulin resistance
                                                                                   and diminishing insulin production, medications used
        The following article briefly discusses recommend-                         to treat type 2 diabetes target these different problems.
    ed approaches to diabetes management; however, treat-                          Some drugs make the body more sensitive to the effects
    ment should always be individualized and will almost                           of insulin, some cause the pancreas to release more
    certainly change over time. Speak to your doctor if you                        insulin, some reduce the output of glucose from the liv-
    have any questions about your medications or any aspects                       er, while others delay the release of glucose from foods.
    of your treatment. Be sure to tell him/her if you are                              People with type 2 diabetes often require two or more
    taking any “natural” or herbal products; these products                        medications and/or insulin to achieve blood glucose tar-
    may not be closely regulated or have undergone the rig-                        gets. Despite the best efforts of patients and their diabetes
    orous safety testing required for prescription drugs, and                      care team, in type 2 diabetes, insulin production and blood
    can contain potent ingredients. Lifestyle changes remain                       glucose control diminish over time. For this reason, your
    an essential part of achieving all your diabetes targets                       physician will likely make changes to your medications
    and overall well-being.These include achieving and main-                       and doses as you get older or as your health changes.
    taining a healthy weight, regular exercise (both aerobic                           Finally, many people with type 2 diabetes would bene-
    and resistance exercises), good nutrition, stress man-                         fit greatly from insulin. If you are having trouble reach-
    agement and, of course, quitting smoking.                                      ing your blood glucose targets, speak to your doctor about


    D      iabetes medications work best when they’re tak-
           en exactly as prescribed.Ask your doctor, pharma-
    cist or diabetes educator these important questions:
                                                                                       there anything I can do to reduce them?
                                                                                   question: Do these medications cause hypoglycemia
                                                                                     (low blood glucose levels)? If so, how do I recognize,
    question: How often and when do I need to take my                                prevent and treat hypoglycemia?
       pills and/or insulin?                                                       question: How should I store these medications?
    question: Do I take my medications with meals? If so,                          question: Are there generic versions of medications
       do I take them right before each meal or at a certain                         that might cost less?
       time after each meal? (These are particularly signifi-                      question: Will these medications interact with other
       cant questions because some diabetes medications                              (non-diabetes) prescription medications that I’m taking?
       are specifically designed to work between or after                          question: Will they interact with herbal remedies or
       meals.)                                                                       over-the-counter medications, such as cough syrup?
    question: When should I expect to see a reduction in                           question: Can I safely drink alcohol while taking these
       my blood glucose levels?                                                      medications?
    question: What should I do if I miss a dose of my med-                         question: If I become pregnant, could these medica-
       ication?                                                                      tions be dangerous to my baby? If so, what are my
    question: Should I expect any side effects? If so, is                            options for birth control?

6   Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007
whether starting insulin might be appropriate for you.               s “I hate taking all these pills!”
s Blood pressure medications                                         F O R M O S T P E O P L E W I T H D I A B E T E S , medications are
A C H I E V I N G B L O O D P R E S S U R E TA R G E T S in people   a reality of diabetes management. If you get discouraged,
with diabetes often requires two or more blood pres-                 remember that achieving your targets will reduce your
sure-lowering drugs. For this reason, the Canadian Dia-              risk of complications.You may be able to reduce the num-
betes Association Clinical Practice Guidelines state that            ber of pills you take, or reduce the dosage of certain pills,
the issue of which kind of drug to use first may be less             if you lose weight, modify some aspects of your diet and
important than the need to use more than one drug.                   adopt (and stick with) a regular exercise program.
Most people with diabetes should be taking an ACE                        If you find you are forgetting to take your pills or if
inhibitor, which not only lowers blood pressure, but also            cost is a problem, speak to your doctor or pharmacist
lowers overall cardiovascular risk.                                  about ways to simplify your medication regimen. Gener-
s Cholesterol medication                                             ic pills are less expensive than brand-name medications,
I N AU T U M N 2006, the Canadian Diabetes Association               and some combination products are available that not
released new guidelines for the treatment of lipids (blood           only reduce the number of pills to take, but also reduce
fats such as cholesterol) in adults with diabetes.The drugs          pharmacy dispensing charges and overall drug costs.
of choice to lower LDL are known as statins.These med-               Once-a-day long-acting formulations of some medica-
ications are highly effective and safe, and most people              tions also simplify medication regimens. A medication
should be able to reach their LDL target on a statin alone.          dispenser called a dosette (available at any pharmacy)
s Cardiovascular protection                                          can help you keep track of what pills to take and when.
P E O P L E W I T H D I A B E T E S are at high risk of cardiovas-   Many pharmacies offer blister-packaging services (where
cular diseases such as heart attacks and stroke. For this            all pills taken at a certain time of day are combined into
reason, the Canadian Diabetes Association Clinical Prac-             separate “bubbles”) to help you take the correct amount
tice Guidelines recommend the use of ACE inhibitors                  of your medications at the right time of day.
and low-dose ASA for general cardiovascular protection                   Finally, if you are bothered by side effects, speak to your
in most people with diabetes. If you are not already tak-            doctor or pharmacist. Many people simply stop taking the
ing these medications, ask your doctor if they would be              pills, but many side effects can be managed by changing
appropriate for you.                                                 the dose or the timing of when you take the pill.


L    ife can be hectic, and staying on top of your medica-
     tion schedule requires special attention. Here are a
few ideas that might help:
                                                                     herbal products.This will help prevent medication-relat-
                                                                     ed problems, such as drug interactions, and lead to a clos-
                                                                     er relationship with your pharmacist – an accessible and
s Make sure you understand each medication you’re                    valuable healthcare resource.
taking and why you’re taking it. If you’re not certain, ask          s Use a pill box/dosette to help you organize your daily/
your doctor, pharmacist or diabetes educator to explain.             weekly pills.
s Find out what side effects might be associated with
your drugs, and which symptoms should be reported.                   You may need to try several combinations of medications
s Never stop taking a prescribed medication without                  at different dosages to find what works best for you.
checking with your healthcare provider, even if you don’t            Speak with your doctor, pharmacist or diabetes educa-
feel any effect from it. Many drugs, especially blood pres-          tor if you’re having trouble remembering to take your
sure or cholesterol pills, make a difference you usually             medications or if you’re bothered by side effects. Med-
can’t detect.                                                        ications will only work if you take them, and your doc-
s Deal with one pharmacy for all your medications, and               tor, pharmacist and diabetes educator can help you find
be sure to talk to your pharmacist before taking any                 the simplest, most effective treatment.
drugs, including over-the-counter (non-prescription) and

                                                                               Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007   7
Your guide to diabetes medications
             HOW TO USE THIS GUIDE                                                 BIGUANIDES
             • Find the name of your medication(s) in                              s Medication in this class
               the list below (both generic and brand                              Metformin is the only medication in this class that’s
               names are listed).                                                  available in Canada. It’s sold as a generic drug and
             • Turn to the page beside your medication                             under the brand names Glucophage and Glumet-
               name. Each medication belongs to a drug                             za, the latter of which is a slow-release form of
               family, or class. Medications that have                             the medication.
               similar actions in the body are grouped in                          s How this medication works
               the same drug class.This guide provides                             This drug acts mainly by helping the liver reduce
               information on drug classes, as well as                             glucose production. It also helps muscles use glu-
               on the medications within each class.                               cose from the bloodstream. Both of these actions
                                                                                   reduce blood glucose levels.
             My prescription                                 …turn to
                                                                                   s Advantages
             label says …                                            page
             Acarbose . . . . . . . . . . . . . . . . . . . . . . . . .10
                                                                                   Metformin is the recommended pill for most peo-
             Actos . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
                                                                                   ple with type 2 diabetes and is especially recom-
             Amaryl . . . . . . . . . . . . . . . . . . . . . . . . . . . .9       mended for individuals who are overweight.
             Avandamet . . . . . . . . . . . . . . . . . . . . . . .10             Metformin does not cause weight gain or hypo-
             Avandaryl . . . . . . . . . . . . . . . . . . . . . . . .10           glycemia and works well in combination with some
             Avandia . . . . . . . . . . . . . . . . . . . . . . . . . . .8        other diabetes pills and insulin.There is some evi-
             DiaBeta . . . . . . . . . . . . . . . . . . . . . . . . . . .9        dence that metformin can reduce the risk of heart
             Diamicron . . . . . . . . . . . . . . . . . . . . . . . . .9          problems in overweight patients and improve lipid
             Diamicron MR . . . . . . . . . . . . . . . . . . . . . .9             (blood fat) levels.
             Euglucon . . . . . . . . . . . . . . . . . . . . . . . . . .9         s What you should know
             Gliclazide . . . . . . . . . . . . . . . . . . . . . . . . . .9       This medication may cause nausea, diarrhea and gas
             Glimepiride . . . . . . . . . . . . . . . . . . . . . . . .9          when you start taking it.Taking the pills with meals
             Glucobay . . . . . . . . . . . . . . . . . . . . . . . . .10          and increasing the dose slowly can reduce these side
             GlucoNorm . . . . . . . . . . . . . . . . . . . . . . .10             effects. In some people, metformin can affect the
             Glucophage . . . . . . . . . . . . . . . . . . . . . . . .8           absorption of both folic acid and vitamin B12. If your
             Glumetza . . . . . . . . . . . . . . . . . . . . . . . . . .8         folic acid or B12 levels are low, your doctor will rec-
             Glyburide . . . . . . . . . . . . . . . . . . . . . . . . .9          ommend a supplement.
             Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . .11           In addition, if used in people with significant
             Metformin . . . . . . . . . . . . . . . . . . . . . . . . .8          heart, kidney or liver problems, metformin can
             Nateglinide . . . . . . . . . . . . . . . . . . . . . . .10           cause a very rare but serious condition called lac-
             Orlistat . . . . . . . . . . . . . . . . . . . . . . . . . .11        tic acidosis.
             Pioglitazone . . . . . . . . . . . . . . . . . . . . . . . .8
             Prandase . . . . . . . . . . . . . . . . . . . . . . . . .10
                                                                                   INSULIN SENSITIZERS
             Repaglinide . . . . . . . . . . . . . . . . . . . . . . .10
                                                                                   s Medications in this class
             Rosiglitazone . . . . . . . . . . . . . . . . . . . . . . .8
                                                                                   There are two medications in this class: rosiglita-
             Starlix . . . . . . . . . . . . . . . . . . . . . . . . . . .10
             Xenical . . . . . . . . . . . . . . . . . . . . . . . . . .11
                                                                                   zone, which is sold under the brand name Avan-
                                                                                   dia, and pioglitazone, which is sold under the brand
             Note: Generic drug companies often place a prefix at                  name Actos.
             the beginning of drug names, for example, Apo, Novo,                  s How these medications work
             Gen or Ratio, among others.To find your medication on                 These medications increase the body’s sensitivity
             this list, remove the prefix; for example,“Apo-glyburide”             to its own insulin, allowing the cells to use glucose
             would be found under the listing ”Glyburide.”                         more efficiently.These pills are recommended in

8   Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007
combination with other diabetes pills. For people            dose was reduced or the drug was stopped. If you
who are overweight and unable to reach their blood           notice a change in your vision after starting an
glucose targets, the Canadian Diabetes Associa-              insulin sensitizer, inform your doctor and have
tion’s Clinical Practice Guidelines recommend an             your eyes checked.
insulin sensitizer in combination with metformin.
For individuals who have very high blood glucose             INSULIN SECRETAGOGUES
levels when they’re diagnosed, the guidelines rec-           Although these pills are commonly prescribed for
ommend this combination as the initial treatment.            diabetes, the Canadian Diabetes Association’s Clin-
s Advantages                                                 ical Practice Guidelines recommend them only as
Insulin sensitizers do not cause hypoglycemia (low           a third choice.The Association recommends that
blood glucose levels). New evidence suggests that            for most people, metformin and insulin sensitiz-
insulin sensitizers can possibly reduce the risk of          ers should be tried first.
heart disease.As well, a major clinical study called            Insulin secretagogues fall into two classes: sul-
ADOPT (A Diabetes Outcome Progression Tri-                   fonylureas and non-sulfonylureas.
al) recently determined that rosiglitazone, when             s How these medications work
used by people newly diagnosed with diabetes,                Secretagogues work by stimulating the pancreas to
can help them maintain blood glucose control                 secrete more insulin.All secretagogues reduce blood
longer than glyburide or metformin.                          glucose levels equally well, except for Starlix. (See
s What you should know                                       below.)
It can take two to three months for insulin sensitiz-
ers to reach full effectiveness.Take the pills exactly       SULFONYLUREAS
as prescribed, even if there is no immediate improve-        s Medications in this class
ment in your blood glucose. Many doctors try oth-            There are three medications in this class that are sold
er medications before prescribing an insulin sensitizer,     in Canada: glyburide (sold as a generic and under
because insulin sensitizers are more expensive than          the brand names DiaBeta and Euglucon), gliclazide
other diabetes pills. However, there is evidence that        (sold as a generic and under the brand names Diami-
these pills have the most benefit if taken earlier, rather   cron and Diamicron MR) and glimepiride (sold
than later, in the course of type 2 diabetes.                under the brand name Amaryl).Two other drugs,
    Insulin sensitizers can cause fluid retention and        chlorpropramide and tolbutamide, are available in
increase total body fat, thereby contributing to             Canada but are rarely used.
weight gain. People with congestive heart failure            s How these medications differ from one
must not take these medications.The use of insulin              another
sensitizers in people who already take insulin is            These medications work in the same way, but dif-
not an approved combination in Canada.The com-               fer in how long they take to work. Amaryl and
bination is approved in the United States, howev-            Diamicron MR are long-acting and need to be tak-
er. If your doctor prescribes insulin and an insulin         en only once a day. Compared with glyburide (also
sensitizer in combination, he or she will explain            long-acting), they cause less weight gain and less
that there may be an increased risk of fluid reten-          hypoglycemia. Glyburide is more likely to cause
tion or congestive heart failure and may monitor             weight gain and very low blood glucose levels
your health for any early changes.                           (hypoglycemia); it is not the medication of choice
    A few cases of macular edema (swelling of the            for people who are at high risk of hypoglycemia
retina in the area responsible for central vision)           (such as the elderly).
have been reported with rosiglitazone.The risk of            s What you should know
this happening is very low. In most cases, the con-          All of the sulfonylureas can cause hypoglycemia;
dition improved or returned to normal when the               however, there is usually less risk using gliclazide

                                                                     Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007   9
Your guide to diabetes medications
              or glimepiride. If you are taking a sulfonylurea,                     piride).They are available in several fixed-dose
              learn how to recognize, prevent and treat low                         combinations.
              blood glucose levels.
              NON-SULFONYLUREAS                                                     INHIBITORS
              s Medications in this class                                           s Medication in this class
              There are two medications in this category that                       The only medication in this class is acarbose, sold
              are available in Canada: repaglinide (sold under                      under the brand name Glucobay (it was former-
              the brand name GlucoNorm) and nateglinide (sold                       ly called Prandase).
              under the brand name Starlix).                                        s How this medication works
              s How these medications work                                          Glucobay lowers blood glucose levels after meals.
              Like the sulfonylureas, non-sulfonylureas work by                     Taken with the first bite of a meal, Glucobay
              stimulating the pancreas to secrete more insulin;                     works in the intestine to block an enzyme that
              however, they are designed to do this for four to                     breaks down complex carbohydrates (such as those
              five hours, just covering mealtimes.                                  found in bread and potatoes) into glucose, which
              s Advantages                                                          is a simple carbohydrate. This slows down the
              Non-sulfonylureas work quickly and lower blood                        absorption of glucose from these foods, giving the
              glucose levels after a meal.They are especially use-                  pancreas more time after meals to secrete enough
              ful for people who have irregular meals, such as shift                insulin to lower blood glucose levels.
              workers, and for those whose blood glucose levels                     s Advantages
              tend to be high after meals. As well, they are less                   Glucobay does not cause hypoglycemia and there
              likely to cause hypoglycemia than sulfonylureas.                      are no serious side effects. One major study has
              s What you should know                                                shown that the medication can help prevent the
              Both GlucoNorm and Starlix need to be taken                           development of diabetes in people with predia-
              with every meal, which can be challenging for                         betes. It can be used in combination with other
              some people. If you have to skip a meal, do not                       oral diabetes medications and with insulin.
              take the pill planned for that meal. As hypo-                         s What you should know
              glycemia is a risk, people taking this medication                     Glucobay can cause unpleasant side effects such
              need to learn how to recognize, prevent and treat                     as gas, bloating and flatulence.To reduce these side
              low blood glucose levels.                                             effects, a low starting dose can be prescribed, and
                 The main difference between GlucoNorm and                          then the dose can be slowly increased. Although
              Starlix is that Starlix reduces blood glucose to a                    Glucobay won’t cause hypoglycemia, many peo-
              lesser degree than GlucoNorm.                                         ple who take it also take other diabetes medica-
                                                                                    tions that can cause hypoglycemia.
              COMBINATION PILLS                                                        If hypoglycemia develops while taking Glucobay,
              Combination pills, which mix common diabetes                          it must be treated with dextrose tablets, honey or
              medications into a single pill, reduce the number                     milk. Because of the way Glucobay works, some
              of pills you need to take.They can also save you                      typical treatments for hypoglycemia – such as table
              money because you pay only one pharmacy dis-                          sugar, regular soft drinks or fruit juice – are not
              pensing fee.The fixed combination of doses, how-                      effective. People with chronic intestinal disease
              ever, means there is less flexibility to tailor dosages               and kidney failure should not take Glucobay.
              to individual needs.
                 The combination pills currently available in                       ANTIOBESITY DRUGS
              Canada are Avandamet (rosiglitazone and met-                          s Medication in this class
              formin) and Avandaryl (rosiglitazone and glime-                       Although there are other weight-loss medications,

10   Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007
only orlistat (sold under the brand name Xenical)        you need to monitor your blood glucose levels reg-
is approved for the treatment of diabetes in peo-        ularly. (See chart on page 12 for more informa-
ple who are obese.                                       tion on the various insulins available in Canada.)
s How this medication works                                  The insulin regimen your doctor prescribes
Xenical is taken with meals and works in the intes-      will depend on your treatment goals, lifestyle,
tine to decrease the absorption of the fat from foods.   diet, age, general health, risk of low blood glu-
The undigested fat is then eliminated in the feces.      cose, your preference and financial circumstances.
s Advantages                                                 The goal of any insulin regimen is to mimic, as
Xenical is typically recommended for individuals         closely as possible, insulin secretion in people
who are obese and as part of a strategy to lose          without diabetes. In people without diabetes, the
weight and avoid regaining lost weight, while            pancreas provides a constant supply of insulin
improving blood glucose levels.                          (called basal insulin) and secretes extra insulin
s What you should know                                   when needed, such as when you eat (called bolus
Most people who take Xenical lose modest amounts         or meal insulin).Your insulin regimen, therefore,
of weight if they also reduce their caloric intake and   will have a basal component to provide some lev-
adopt a regular exercise program.The medication          el of insulin at all times, as well as a bolus com-
is not a replacement for a healthy meal plan and         ponent to manage blood glucose over mealtimes.
regular activity.Those who take Xenical must fol-            The best way to learn about insulin is by con-
low a low-fat diet and divide their fat, carbohydrate    sulting a diabetes educator.Ask your doctor for a
and protein intake over three meals per day.             referral. A diabetes educator will help you learn
    With a high-fat diet, excess fat in the intestine    about injection options (syringes, jet injectors,
can result in fatty or oily stools or even in the        pens, pumps), how to adjust your insulin dose
inability to control bowel movements.                    based on your blood glucose monitoring results,
    This medication can reduce the absorption of         how to time your meals and snacks, how to match
some vitamins, so taking a multivitamin daily is         your carbohydrate intake to your insulin dose, the
usually recommended. Although Xenical is                 effects of exercise, and how to care for and store
approved as a medication to lower blood glucose          your insulin. Importantly, you will learn how to
levels, its effect is modest. Because of its weight-     prevent, recognize and treat low blood glucose
loss and blood glucose-lowering effects, though,         levels (hypoglycemia).
Xenical can help some people with prediabetes                Many people with type 2 diabetes resist taking
avoid developing diabetes.                               insulin.They feel that taking insulin means that
                                                         they’re sick or have somehow “failed” to manage
INSULINS                                                 their diabetes. Needing insulin does not mean that
People with type 1 diabetes require insulin every        you have failed in any way. Some people find it help-
day of their life. People with type 2 diabetes often     ful to think of insulin therapy as a natural hormone
need insulin to help them meet their blood glu-          replacement therapy. In other words, insulin injec-
cose goals. In type 2 diabetes, insulin can be tak-      tions simply replace a natural hormone that the body
en alone or with diabetes pills.                         can no longer produce in sufficient quantities.
   Insulins are classified by their duration of action       Other individuals resist taking insulin because
(how long they work).They also differ in their           they’re afraid of needles or feel it will be embar-
onset of action (how quickly they start working)         rassing to give themselves injections in public.
and when this action peaks (when they are most           Insulin pens are an excellent alternative to
effective). Insulin is measured in units. By under-      syringes; they’re virtually painless and can be used
standing how your insulin works, you can time            discreetly. Also, using an insulin pen can help
your meals, snacks and exercise. If you take insulin,    reduce dosing errors.

                                                                 Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007   11
Your guide to diabetes medications
              TYPES OF INSULIN

              Insulin type/action                                            Brand names             Basal             Dosing schedule
              (appearance)                                                   (generic name           or bolus?
                                                                             in brackets)

              Rapid-acting analogue (clear)                                  Humalog (insulin        Bolus             Usually taken right
                 Onset: 10–15 minutes                                        lispro)                                   before eating, or to
                 Peak: 60–90 minutes                                         NovoRapid (insulin                        lower high blood
                 Duration: 4–5 hours                                         aspart)                                   glucose levels

              Short-acting (clear)                                           Humulin-R               Bolus             Taken about 30 min-
                 Onset: 0.5–1 hour                                           Novolin ge Toronto                        utes before eating, or
                 Peak: 2–4 hours                                                                                       to lower high blood
                 Duration: 5–8 hours                                                                                   glucose levels

              Intermediate-acting (cloudy)                                   Humulin-N               Basal             Often taken at bed-
                  Onset: 1–3 hours                                           Novolin ge NPH                            time, or twice a day
                  Peak: 5–8 hours                                                                                      (morning and bed-
                  Duration: up to 18 hours                                                                             time)

              Extended long-acting analogue                                  Lantus (insulin         Basal             Usually taken once
              (clear and colourless)                                         glargine)                                 or twice a day
                   Onset: 90 minutes                                         Levemir (insulin
                   Peak: none                                                detemir)
                   Duration: 24 hours

              Premixed (cloudy)                                              Humalog Mix 25          Combination       Depends on the
              A single vial contains a fixed ratio                           Humulin (20/80,         of basal and      combination
              of insulins (the numbers refer to                              30/70)                  bolus insulins
              the ratio of rapid- or short-acting                            Novolin ge (10/90,*
              to intermediate-acting insulin in                              20/80,* 30/70, 40/60,
              the vial)                                                      50/50)

              *Novolin ge 10/90 and 20/80 will not be available after July 2007. Please visit for further information.


              ☛ A1C: 7% or lower.                                                           7 mmol/L (or 4 to 6 mmol/L if your target A1C is
              (Some people with diabetes aim for 6% or lower,                               6% or lower).
              but this should be your target only if you and your                           ☛ Blood glucose level 2 hours after meals:
              doctor feel you can achieve it safely.)                                       5 to 10 mmol/L (or 5 to 8 mmol/L if your target
              ☛ Blood glucose level before meals: 4 to                                      A1C is 6% or lower).

12   Y O U R G U I D E T O D I A B E T E S M E D I C AT I O N S   •   SPRING 2007
Pharmacists on your team
What can they do for you?                                         under control. She looked at the memory in his meter
                                                                  and discovered that he never tested at night.When she
BY RUTH HANLEY                                                    asked why, he explained, “I’m always high then, so I
                                                                  don’t bother testing.”
             H E L A S T T I M E you picked something up at a         Pharmacists probably see you more often than any oth-

T            pharmacy, did you pick up some information
             while you were there? If you didn’t, you’re
missing out on a great resource.
                                                                  er healthcare professional on your team, and they have
                                                                  the expertise to pick up on little signals that could point
                                                                  to a bigger problem. For example, they might ask you
   Pharmacies offer the latest drug information, of course        questions because they’ve noticed that you’re picking up
– but that’s just part of the information service they can        Polysporin antibiotic cream twice in one week (possible
provide. Pharmacists can also help you interpret infor-           foot injury), or buy a bottle of Maalox antacid every time
mation you’ve found in other places, such as mailings,            you pick up your prescription (possible stomach prob-
magazines or the Internet. “Rather than a dearth of infor-        lems).They may suggest that you visit your doctor or, if
mation, people today are drowning in information,” says           you wish, may talk to the doctor on your behalf.
Morna Cook, a community pharmacist in Winnipeg and                    That advocacy role is important, because some peo-
winner of the Canadian Diabetes Association’s 2006                ple present a falsely positive front to their physician, says
National Volunteer of theYear Award. “They need some-             Cook. She recalls one patient who had terrible breath
body on their team, somebody to sort it all out.”                 because of gum problems. Her dentist didn’t know she
   Sometimes people simply don’t understand the infor-            had diabetes – and her doctor didn’t know she was “fudg-
mation provided – but other times the information can             ing” the results of her blood glucose readings because she
be downright “murky,” says Cook, whether it’s over-tech-          didn’t want the doctor to know her diabetes wasn’t under
nical or oversimplified, or just plain misleading. Cook           control.The problem got fixed because Cook and the
recalls one woman who came to her concerned about                 doctor were brainstorming about medical reasons for the
some promotional material she had received in the mail            patient’s bad breath, and Cook asked if he had double-
about her meter.“She thought there was something wrong:           checked the patient’s monitor results lately. “For some
that her meter was being recalled, that all her numbers           reason, people think of the doctor on a different level, as
were wrong, or maybe she didn’t have diabetes at all!”            judgmental,” says Cook, “whereas very few people have
   Pharmacists also play an important role in reinforcing         ‘white coat syndrome’ with pharmacists.”
information you’ve already received about your treatment              As well as working with other healthcare profession-
from other members of your healthcare team.And because            als on your behalf, pharmacists can also connect you with
you’re probably in and out of the pharmacy on a regular           local support groups, or help you navigate your way
basis picking up supplies and medications, it’s easy for you      through government drug benefit and private insurance
to get that information when you need it, rather than tak-        programs.They can also be information clearinghouses
ing it all in at once. “We have a ton of information about        for brochures or seminars on diabetes (some provide dia-
diabetes,” says Cook. “But if I blast that at the person all at   betes education programs themselves), and for suppliers
once, they’re absolutely overwhelmed and, when they               such as MedicAlert or orthotics manufacturers.
come to need it, they’ve forgotten about it.They need to              In order for your pharmacist to provide the best care,
know that, when the time is right for them, this is one of        you need to do your part too, says Cook. “It’s important
the places for understandable, personalized information.”         that you deal with somebody who is acquainted with your
    It may be a case where the pharmacist realizes you            entire healthcare profile.” Make sure the pharmacist knows
need more information even though you think you’re                about all of your health conditions and allergies, and always
doing just fine. “It doesn’t matter if you know what your         use the same pharmacy whether you’re purchasing dia-
blood glucose reading is, if you have no idea what to do          betes supplies, herbals, vitamins, or prescription or over-
about it,” says Cook. She points to her own brother, who          the-counter medications – that makes it easier for pharmacy
has diabetes and was having trouble getting his diabetes          staff to pick up on potential problems such as interactions.

Keep a logbook of your blood glucose levels and medications, and

review the results regularly with your healthcare professional.
      Drug research
      From test tube to you                                            s Design: Was the trial double-blinded (meaning both
                                                                       patients and researchers were unaware which treatment
      BY CYNTHIA N. LANK AND RUTH HANLEY                               the patient was receiving, to ensure they didn’t subcon-
                                                                       sciously favour one over the other)? If the trial compares
                                                       a new med-      the study drug to another drug, is it a fair comparison?

                 H E P RO C E S S O F D E V E L O P I N G
                  ication is extremely long and expensive, and         How long did the trial last? In earlier stages of testing, the
                  typically follows more or less the same pattern.     drug may be tested for a short period, but in later stages,
         First, scientists study chemical and physical processes       it should be tested over several months or even years to
      that occur at the level of genes, molecules and cells, in        see whether the drug remains useful or causes dangerous
      order to better understand the “pathways,” or processes,         side effects when used for a long period of time.
      involved in a certain aspect of a disease.They then con-         s Researchers: Who is working on the trial and who
      duct experiments to test their theories on laboratory ani-       is providing financial support? Many drug trials are spon-
      mals or in isolated cells. Next come tests on ways to alter      sored by the drug’s manufacturer; there is nothing intrin-
      the processes that appear to be contributing to the devel-       sically wrong with this, since the company naturally
      opment of the disease or enhance processes that may offer        needs to ensure that its product is effective and safe.
      protection against the disease.                                  However, it is essential that the design of the trial does
         These interventions are then studied in animal mod-           not somehow favour the company’s product.
      els. If a given intervention is found to be safe and effec-      s Subjects: Who was enrolled? If they’re people who
      tive, researchers conduct a series of studies, in which          have the disease being treated, but who are otherwise
      the suggested treatment is used in ever-larger groups            healthy, will the trial results be applicable in the real world,
      of people.These studies must adhere to strict ethical            where patients may have more than one health problem?
      guidelines to ensure the safety of the volunteers who            s Results: Numbers can mean a lot of things, depend-
      are willing to try experimental treatments.These trials          ing on how they’re interpreted. For example, a study
      are specifically designed to detect any potential safety         might show that 50 per cent of the people in the active
      problems as well as the effectiveness of the treatment.          treatment group were cured.That might sound amaz-
         Finally, drugs must be approved for use and sale in           ing, until you read further and find that 40 per cent of
      Canada by Health Canada, the government agency that              those in the placebo group were also “cured.”
      specifies exactly how and in whom the drug may be                s Reporting of results: Bias can creep in, intention-
      used. In addition, ongoing evaluations are required to           ally or not, when study results are reported. For exam-
      collect safety data over the long term after a drug is           ple, researchers might report on the beneficial effects of
      launched. If serious or frequent side effects are discov-        their drug at the six-month stage of the trial, but not report
      ered, a drug will be taken off the market.                       at the 12-month stage, if the results are not as beneficial.
                                                                       s News media: General reporters may not be qual-
      INTERPRETING THE RESULTS                                         ified to accurately report on the intricacies of a clinical
      OF DRUG TRIALS                                                   trial; also, they may oversimplify their report because
      A T E AC H S T E P I N T H E P RO C E S S , drug trial results   they want to grab the consumer’s attention with a dra-
      are studied by other researchers and clinicians.They             matic headline, or cram a lot of complex information
      need to know whether the trial was properly designed             into a very small story.
      and results were correctly interpreted. Ideally, trials              It’s clear that interpreting the results of a clinical trial
      should be replicated by other researchers to ensure that         is not an easy matter.That’s why it’s important, if you’ve
      the same results will occur. Consumers also need to              heard about a clinical trial that seems to have exciting impli-
      become “scientifically literate” if they want to be able         cations for you, to discuss it with a healthcare profession-
      to understand what trial results truly mean.                     al you trust. He or she can review the information and help
         Here are a few examples of questions you should               you determine whether the results are as exciting as they
      think about when reviewing a trial’s results.                    seem to be.

      Make and keep appointments with your dietitian, an important
      member of the diabetes healthcare team.

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