Category Archives: Drugs for Diabetes

Drugs for Diabetes: Insulin Degludec (Tresiba) – A New Long-Acting Insulin

Posted on August 1, 2016 | Comments Off on Drugs for Diabetes: Insulin Degludec (Tresiba) – A New Long-Acting Insulin

Tresiba joins other long-acting insulins like insulin glargine (Lantus), insulin detemir (Levemir), and good ol’ NPH insulin. While FDA-approved in the U.S. only this year, it’s been used in other countries for some time. Insulin degludec will have different names depending on the country.

Who Is It For?

  • Adults with type 1 and 2 diabetes
  • Not for diabetic ketoacidosis
  • We have no good data on use in children (under 18), pregnant women, and nursing mothers

How Long Does It Work?

It will last for at least 30 hours in most users. After that, effectiveness starts to taper off but some effect may be seen as long as 42 hours after the injection.

What Is Its Role In Treating Diabetes?

Insulin degludec is a basal insulin, meaning that it runs in the background continuously. It’s not designed to reduce blood sugar that rises after a meal. If your pancreas still makes insulin, release of that insulin may reduce after-meal glucose levels adequately. Otherwise, after-meal glucose elevations are addressed with bolus insulin injections. Bolus-type insulins are the rapid-acting ones like Humalog and Novolog.

Most NPH insulin users, and some insulin glargine (Lantus) users, need the injection twice daily. Because of its long duration of action, Triseba users should never need more than one injection daily. I don’t have much experience with Levemir because the hospital where I work doesn’t stock it.

Triseba users should take it at about the same time daily. If you miss that time by up to five or six hours either way, it probably won’t matter.

What’s the Dose?

For type 2 diabetics who have never used insulin, the starting dose is typically 10 units/day.

For type 1’s switching from other insulins, the usual starting dose is one-third to one-half of the total daily insulin dose, plus rapid-acting bolus insulin around meal times for the remainder.

Change the dose no more often than every three or four days.

How Much Does It Cost?

I don’t know. Likely more than some of the other basal insulins.

Steve Parker, M.D.

PS: Click here for full prescribing information.

PPS: If glargine, degludec, and detemir sound like Greek to you, you’ll appreciate my book.

No degludec up in here!

No degludec up in here!

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More Patients With Impaired Kidney Function Qualify for Metformin

Posted on July 28, 2016 | Comments Off on More Patients With Impaired Kidney Function Qualify for Metformin

Recently the U.S. Food and Drug Administration revised their guidelines for physicians regarding use of metformin in patients with kidney impairment. This may make more patients candidates for the drug.

Physicians have been advised for years that type 2 diabetics with more than minimal kidney impairment should not be given metformin. Why? Metformin in the setting of kidney failure raises the risk of lactic acidosis.

The traditional test for kidney impairment is a blood test called creatinine. When kidneys start to fail, serum creatinine rises. Another way to measure kidney function is eGFR, which takes into account creatinine plus other factors.

By the way, you can’t tell about your kidney function simply from the way you feel; by the time you have signs or symptoms of renal failure, the process is fairly advanced.

The FDA now recommends not using  metformin if your eGFR (estimated glomerular function rate) is under 30 ml/min/1.73 m squared), and use only with extreme caution if eGFR drops below 45 while using metformin. Don’t start metformin if eGFR is between 30 and 45. Your doctor can calculate your eGFR and should do so annually if you take metformin.

Steve Parker, M.D.

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Do SGLT2 Inhibitors Increase the Risk of Amputations in Diabetics?

Posted on July 10, 2016 | 1 comment

Good question. But we don’t know the answer yet.

European authorities and even the U.S. Food and Drug Administration are looking into the possible connection. Stay tuned. Visit The Low Carb Diabetic site (link below) for more details.

“The European Medicines Agency (EMA)’s Pharmacovigilance Risk Assessment Committee (PRAC) has extended the scope of its investigation into the possible link between the sodium glucose cotransporter 2 (SGLT2) inhibitor canagliflozin (Invokana, Vokanamet, Janssen) and amputations to include other drugs of the same class.

Now, the PRAC’s review will include the other SGLT2 inhibitor medicines dapagliflozin (Farxiga, Xigduo XR, AstraZeneca), and empagliflozin (Jardiance, Boehringer Ingelheim), based on the determination that the potential risk may be relevant for them as well.”

Source: The Low Carb Diabetic: EMA Extends Amputation Investigation to All SGLT2 Inhibitors

Steve Parker, M.D.

PS: SGLT2 inhibitors are the drugs that reduce blood glucose by shunting it into your urine. Makes more sense to me instead to reduce your blood sugar by eating fewer carbohydrates, the primary source of blood sugar in most folks.

Update May 17, 2017: On May 16, 2017, the U.S. Food and Drug Administration ruled that canagliflozin doubles the risk of foot and leg amputations, compared to placebo.

 

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Does Diabetes Drug Empagliflozin Reduce Heart Disease Risk?

Posted on November 17, 2015 | Comments Off on Does Diabetes Drug Empagliflozin Reduce Heart Disease Risk?
diabetic mediterranean diet, Steve Parker MD

Pharmacist using her advanced degree to count pills

Larry Husten writing at CardioBrief mentions a recent press release alleging that empagliflozin reduces cardiovascular disease risk.

Larry points out a problem with diabetes drugs that I’ve been harping on for years: we don’t know the long-term outcomes and side effects of most of our drugs. As long as a diabetes drug reduces blood sugar and seems to be relatively safe in the short term, it will be approved for use by the U.S. Food and Drug Administration. Larry writes:

Until now the best thing anyone could say for sure about all the new diabetes drugs was that at least they didn’t kill people. That’s because although these drugs have been shown to be highly effective in reducing glucose levels, a series of large cardiovascular outcomes trials failed to provide any evidence of significant clinical benefit.

Cardiovascular disease is a major stalker of diabetics. I’m talking about heart attacks, strokes, heart failure, sudden cardiac death.

The aforementioned press release touts reduced cardiovascular disease risk in patients taking empagliflozin. What’s missing is any mention of overall death reduction. Even if the drug really prevents heart attacks and strokes, which I doubt, don’t you want to know about overall death rates? I do. For all we know, the drug could promote illness and death from infections and cancer while reducing heart attacks and strokes. The drug’s net effect could be premature death. 

I’m 99% certain the researchers doing the work have the mortality data. Unless they don’t want to know.

By no means am I against drug use. But if I had type 2 diabetes, I’d do all I can with exercise, weight control, and low-carb eating before resorting to new or higher doses of drugs.

Steve Parker, M.D.

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Is Your Doctor Up To Date On Diabetes Treatment?

Posted on August 16, 2015 | Comments Off on Is Your Doctor Up To Date On Diabetes Treatment?

The American Diabetes Association every January updates their Standards of Medical Care in Diabetes. The document is lengthy, highly technical, and written for healthcare providers. Some of you may appreciate it. If I were a non-physician with diabetes, I’d learn as much about it as possible. Remember, no one cares about your health as much as you do. The 2015 version of the standards is called, appropriately enough, Standards of Medical Care in Diabetes—2015.

Updates to the guidlelines include:

  • recommendation not to sit inactively for over 90 minutes
  • pre-meal blood sugar target is now 80 to 130 mg/dl (4.4 to 7.2 mmol/l) instead of the old 70 to 130 mg/dl
  • added SGLT2 inhibitors to the drug treatment algorithm
  • recommended a diastolic blood pressure goal of 90 mmHg or less instead of the old 80 mmHg or less
  • increased the potential pool of statin drug users
  • added a section on management of diabetes during pregnancy

Steve Parker, M.D.

PS: I don’t necessarily agree with or abide by the guidelines.

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Become Your Own Drug Expert

Posted on July 7, 2015 | Comments Off on Become Your Own Drug Expert
Hmmm......did I already take my pills today or not?

Hmmm……did I already take my pills today or not?

I recommend you become the expert on the diabetic drugs you take. Don’t depend solely on your physician or pharmacist. Do research at reliable sources and keep written notes. With a little effort, you could quickly surpass your doctor’s knowledge of your specific drugs.

For example, what are your drug’s side effects? How common are they? How soon do they work? Any interactions with other drugs? What’s the right dose, and how often can it be changed? Do you need blood tests to monitor for toxicity? How often? Who absolutely should not take this drug?

She can't know everything, despite her best efforts

She can’t know everything, despite her best efforts

Along with everything else your doctor has to keep up with, he prescribes about a hundred drugs on a regular basis. You only have to learn about two or three. It could save your life.

Steve Parker, M.D.

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Which Diabetes Drugs Cause Hypoglycemia?

Posted on June 19, 2015 | Comments Off on Which Diabetes Drugs Cause Hypoglycemia?
From 97 to 90 mg/dl

You shouldn’t notice low blood sugars unless under 65-70 mg/dl (3.7 mmol/l)

DRUGS THAT RARELY, IF EVER, CAUSE HYPOGLYCEMIA

Diabetics not being treated with pills or insulin rarely need to worry about hypoglycemia. That’s usually true also for prediabetics. Yes, some type 2 diabetics control their condition with diet and exercise alone, without drugs.

Similarly, diabetics treated only with diet, metformin, colesevalam, sodium-glucose co-transport 2 inhibitor (SGLT2 inhibitor), and/or an alpha-glucosidase inhibitor (acarbose, miglitol) should not have much, if any, trouble with hypoglycemia. The DPP4-inhibitors (sitagliptan and saxagliptin) do not seem to cause low glucose levels, whether used alone or combined with metformin or a thiazoladinedione. Thiazolidinediones by themselves cause hypoglycemia in only 1 to 3% of users, but might cause a higher percentage in people on a reduced calorie diet. Bromocriptine may slightly increase the risk of hypoglycemia. GLP-1 analogues rarely cause hypoglycemia, but they can.

DRUGS THAT CAUSE HYPOGLYCEMIA

Regardless of diet, diabetics are at risk for hypoglycemia if they use any of the following drug classes. Also listed are a few of the individual drugs in some classes:

  • insulins
  • sulfonylureas: glipizide, glyburide, glimiperide, chlorpropamide, acetohexamide, tolbutamide
  • meglitinides: repaglinide, nateglinide
  • pramlintide plus insulin
  • possibly GLP-1 analogues
  • GLP-1 analogues (exanatide, liragultide, albiglutide, dulaglutide) when used with insulin, sufonylureas, or meglitinides
  • possibly thiazolidinediones: pioglitazone, rosiglitazone
  • possibly bromocriptine

Click for a review of drugs for diabetes.

Steve Parker, M.D.

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Have You Heard About Dulaglutide for Diabetes?

Posted on May 24, 2015 | Comments Off on Have You Heard About Dulaglutide for Diabetes?

I forgot to tell you about a new drug for diabetes that hit the market in the U.S. last fall. My preferred initial treatment approach to type 2 diabetes is diet and exercise in most cases, but in many cases that’s not enough.

If your blood sugar’s 400 mg/dl (22 mmol/l) and you’re fairly symptomatic from it, I’ll probably have to start you out on insulin while initiating dietary changes at the same time. Later we’ll try to get you off insulin, onto metformin, and perhaps off drugs entirely within a couple months. (Type 1 diabetics have to keep taking insulin shots, of course.)

Where this new drug fits into our armamentarium isn’t clear. Click here for links to professional association guidelines on diabetes drug prescribing.

In September, 2014, the Food and Drug Administration approved the fourth drug in the GLP-1 analogue class: dulaglutide. The granddaddy in the class is exenatide (Byetta). The new GLP-1 receptor agonist will be sold in the U.S. under the name of Trulicity. It’s a once-weekly injection.

This is only a summary and is liable to change. Get full information from your prescribing healthcare provider and pharmacist.

Resistance training helps control blood sugar

Resistance training helps control blood sugar

Uses

For adults with type 2 diabetes, in conjunction with diet and exercise. It’s not a first-line drug. It can be used by itself or in combination with metformin, pioglitazone, glimiperide (and presumably other sulfonylureas), and insulin lispro (e.g., Humalog, a rapid-acting insulin). The drug has not been tried with basal (long-acting) insulins.

Dose

Start with 0.75 mg subcutaneously every week. Can go up to 1.5 mg weekly if needed.

Adverse Effects

Hypoglycemia is rare, but possible, when GLP-1 analogues are used as the sole diabetes drug. When it happens, it’s rarely severe. But the risk increases substantially when dulaglutide is used along with insulin or insulin secretagogues such as sulfonylureas or meglitinides.

Common side effects are nausea, vomiting, diarrhea, abdominal pain, decreased appetite, dyspepsia, and fatigue.

It might cause thyroid tumors and pancreatitis.

Do Not Use If…

…you have a family or personal history of medullary thyroid cancer, or if you have Multiple Endocrine Neoplasia syndrome type 2 or pre-existing severe gastrointestinal disease. Those who are pregnant or nursing babies should probably not take it since we have no data on safety. Don’t use for diabetic ketoacidosis.

Use only with caution if you have a history of pancreatitis or known liver impairment.

Steve Parker, M.D.

Click for full prescribing information.

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Do the Drug Companies Have Too Much Influence on Diagnosis and Management of Type 2 Diabetes?

Posted on December 28, 2014 | 2 comments
diabetic mediterranean diet, Steve Parker MD

Pharmacist counting pills

MedPageToday has recently completed a series of articles looking at socioeconomic issues related to diabetes drugs that have come onto the market in the last decade. They call it their Diabetes Drugs Investigation. I recommend the entire series to you if you have type 2 diabetes. The authors’ have five major points:

1. “Diabetes drugs improve lab tests, but not much more, particularly in pre-diabetics.” FDA drug approvals were based mostly on whether hemoglobin A1c or blood sugar levels improved, not on improvements in hard clinical endpoints such as risk of death, heart attacks, stroke, blindness, amputations, etc.

2. “Physicians and drug makers have reported diabetes drugs as the “primary suspect” in thousands of deaths and hospitalizations.”

3. “Diabetes drug makers paid physicians on influential panels millions of dollars.” The implication is that the panelists were not totally unbiased in their assessments of drug effectiveness and safety.

4. “Risk of a risk now equals disease.” This is about the latest redefinition of prediabetes which created many more “patients.” Prediabetes can progress to type 2 diabetes over a number of years: one of every four adults with prediabetes develops diabetes over the next 3 to 5 years. Some doctors are even treating prediabetes with diabetic drugs. (I recommend a “diet and exercise” approach.) The authors think the prediabetic label—one third of U.S. adults, including half of all folks over 65—is over-used and over-treated.

5. “The clinical threshold for diagnosing diabetes has crept lower and lower over the past decade.” For instance, in 1997 expert panels lowered the threshold defining diabetes from a fasting blood glucose level of 140 mg/dl (7.8 mmol/l) to 125 mg/dl (6.9 mmol/l). Four million more American adults became diabetics overnight. In 2003, they lowered the threshold for prediabetes from a fasting blood glucose from 110 mg/dl (6.1 mmol/l) to 100 mg/dl (5.6 mmol/l). Boom! 46 million more American prediabetics.

I fully agree with the authors that we don’t know which drugs for type 2 diabetes are the best in terms of prolonging life, preventing diabetes complications, and postponing heart attacks and strokes. Furthermore, we don’t know all the adverse long-term effects of most of these drugs. For instance, metformin had been on the market for over a decade before we figured out it’s linked to vitamin B12 deficiency.

That’s why I try to convince my patients to do as much as they can, when able, with diet and exercise before resorting to one or more drugs. (All type 1 diabetics and a minority of type 2 diabetics must take insulin.) Maybe it’s healthier to focus primarily on drug therapy…but I don’t think so.

RTWT.

Steve Parker, M.D.

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Sulfonylurea Drugs Linked to Heart Disease in Women

Posted on December 26, 2014 | Comments Off on Sulfonylurea Drugs Linked to Heart Disease in Women

…according to this article at Diabetes Care. The study population was the Nurses Health Study. The longer the sulfonylurea was used, the stronger the association with Coronary Heart Disease. CHD is by far the most common cause of heart attacks. On the bright side, the drugs were not linked to stroke risk. Remember, correlation is not causation, blah, blah, blah…

This report is another reason to do all you can to control blood sugars with diet and exercise, minimizing the risks—known and unknown—of long-term drugs.

I rarely start my patients on sulfonylureas these days.

Steve Parker, M.D.

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