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); and • 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 firstname.lastname@example.org. 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 T HE 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 Dana Whitham RD CDE 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) Publisher (Spring, Summer, Autumn,Winter). Email: email@example.com 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 Toronto, Ontario M5G 2R5 this publication does not consti- people affected by diabetes. Assistant Editor Tel: (416) 363-3373 tute endorsement by the Canadi- Patti Sayle Editor-in-Chief Email: firstname.lastname@example.org an Diabetes Association. The Amir Hanna MB BCH FRCPC Editorial Contributors Association is not responsible for Subscriptions FACP Ruth Hanley,Toronto, Ontario any representation as to quality, 1-year subscription and Cynthia Lank, Halifax, Nova Scotia value or effectiveness of any prod- Editorial Advisory Board membership $29.95 ucts, services or methods in this Barbara Cleave RN BSCN CDE Art Direction 1 year subscription only $27.95 publication. Maryann Hopkins BSP CDE Peter Enneson Design Inc. 1 year membership only $10.00 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 QUESTIONS YOU SHOULD ASK ABOUT YOUR MEDICATIONS 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. MEDICATION MANAGEMENT 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. ALPHA-GLUCOSIDASE 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 www.novonordisk.ca for further information. BLOOD GLUCOSE TARGETS ☛ 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 tip 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? T 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. tip Make and keep appointments with your dietitian, an important member of the diabetes healthcare team.
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