Hyperglycemia Management
– Medication Therapy
Janice Frueh, PharmD, BCPS
Associate Clinical Professor
SIUE School of Pharmacy
June 2nd , 2015
Objectives
• Compare and contrast differences in the physiologic effects for glucose
control of newer anti-hyperglycemia medications
• Describe important considerations for effective and safe use of newer
anti-hyperglycemia medications and medication delivery devices
Diabetes
Self-Management
Education and
Support
=
The City of New York. http://www.nyc.gov/html/doh/html/hcp/diabetes-provider-kit.shtml. Accessed on May 2015
Oral & non-insulin injectable medications
Class
-Glucosidase
inhibitors
Agent(s)
Acarbose
Miglitol
Available as
Precose or generic
Glyset
Amylin analogue
Pramlintide
Symlin
Biguanide
Metformin
Glucophage or generic
Bile acid sequestrant
Colesevelam
WelChol
DPP-4 inhibitors
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Nesina
Tradjenta
Onglyza
Januvia
Dopamine-2 agonist
Bromocriptine
Cycloset
Glinides
Nateglinide
Repaglinide
Starlix or generic
Prandin
Class
Agent(s)
Available as
GLP-1 receptor
agonists
Albiglutide
Dulaglutide
Exenatide
Exenatide XR
Liraglutide
Tanzeum
Trulicity
Byetta
Bydureon
Victoza
SGLT2 inhibitors
Canagliflozin
Dapagliflozin
Empagliflozin
Invokana
Farxiga
Jardiance
Glimepiride
Glipizide
Glyburide
Amaryl or generic
Glucotrol or generic
Diaeta, Glynase,
Micronase, or generic
Pioglitazone
Rosiglitazone
Actos or genetic
Avandia
Sulfonylureas
Thiazolidinediones
DPP-4 = dipeptidyl peptidase; GLP-1 = glucagon-like peptide; SGLT2 = sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379..
Insulin medications and delivery devices
Agent
Available as
V-Go® Insulin Delivery System
Prandial
BasalPrandial
Basal
NPH
Glargine U-100
Glargine U-300
Detemir
Lantus (Pen = SoloSTAR)
Levemir (Pen=FlexTouch)
Regular U-500
Regular
Humulin R
Novlooin R
Aspart
Glulisine
Lispro
Novolog (Pen=FlexPen)
Apidra (Pen = SoloSTAR)
Humalog (Pen=KwikPen)
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.
Picture from Valertiras. http://www.go-vgo.com/what-is-vgo. Accessed on March 2015
Picture from Sanofi-Aventis. https://www.afrezza.com. Accessed on May 2015
Afrezza ® Inhaled Insulin
Antihyperglycemic therapy in type 2 diabetes: general recommendations.
Silvio E. Inzucchi et al. Type 2 DM Antihyperglycemic Therapy: General Recommendations Diabetes Care 2015;38:140-149
Antihyperglycemic therapy in type 2 diabetes: general recommendations.
At 3 month f/u = 6 choices for
medication management
Silvio E. Inzucchi et al. ©2015
Type 2byDM
Antihyperglycemic
Therapy: General Recommendations Diabetes Care 2015;38:140-149
American
Diabetes Association
Silvio E. Inzucchi et al. Dia Care 2015;38:140-149
Antihyperglycemic therapy in type 2 diabetes: general recommendations.
At 3 month f/u =LOTS of choices
for medication management
Silvio E. Inzucchi et al. Type 2 DM Antihyperglycemic Therapy: General Recommendations Diabetes Care 2015;38:140-149
PATIENT TAKE HOME MESSAGE:
Individualized Approach to Blood Sugar
Control Targets
•Medication management of hyperglycemia focuses on:
- Efficacy (how much the A1c decreases)
- Hypoglycemia risk (patient AND medication risk factors)
- Impact on weight
- Other side effects
- Cost
Silvio E. Inzucchi et al. Type 2 DM Antihyperglycemic Therapy: General Recommendations Diabetes Care 2015;38:140-149
Liver
Produce
Glucose
Kidney
Normal Glucose Levels
Non-insulin
dependent
• Brain
• Neurons
Eliminate
Glucose
Insulin
dependent
• Liver
• Muscle
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; 2014.
Accessed Online: http://accesspharmacy.mhmedical.com.libproxy.siue.edu/ May 2015.
Hyperglycemia Pathophysiology: Type 2 DM
Impairments in Glucose Regulation
Medications Impacting Glucose Regulation
Impaired insulin secretion
 Deficient insulin release
 Decrease in beta-cell mass +/- function
Sulfonylureas
Insulin resistance
 Muscle cells have impaired intracellular regulation
 Liver cells are less responsive to insulin and
inadequately suppress glucagon levels
Metformin
Thiazolidinediones
Blunted incretin effect
GLP-1 receptor agonists
DPP-4 inhibitors
DPP-4 = dipeptidyl peptidase; GLP-1 = glucagon-like peptide;
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379..
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New
York: McGraw-Hill; 2014. Accessed Online: http://accesspharmacy.mhmedical.com.libproxy.siue.edu/ May 2015.
Oral & non-insulin injectable medications
Class
-Glucosidase
inhibitors
Agent(s)
Acarbose
Miglitol
Available as
Precose or generic
Glyset
Amylin analogue
Pramlintide
Symlin
Biguanide
Metformin
Glucophage or generic
Bile acid sequestrant
Colesevelam
WelChol
DPP-4 inhibitors
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Nesina
Tradjenta
Onglyza
Januvia
Dopamine-2 agonist
Bromocriptine
Cycloset
Glinides
Nateglinide
Repaglinide
Starlix or generic
Prandin
Class
Agent(s)
Available as
GLP-1 receptor
agonists
Albiglutide
Dulaglutide
Exenatide
Exenatide XR
Liraglutide
Tanzeum
Trulicity
Byetta
Bydureon
Victoza
SGLT2 inhibitors
Canagliflozin
Dapagliflozin
Empagliflozin
Invokana
Farxiga
Jardiance
Glimepiride
Glipizide
Glyburide
Amaryl or generic
Glucotrol or generic
Diaeta, Glynase,
Micronase, or generic
Pioglitazone
Rosiglitazone
Actos or genetic
Avandia
Sulfonylureas
Thiazolidinediones
DPP-4 = dipeptidyl peptidase; GLP-1 = glucagon-like peptide; SGLT2 = sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379..
GLP-1 Agonists
Take Home Points: GLP-1 receptor agonists
 Efficacy: ~1% A1c reduction
- Impact post-prandial glucose
- 4 -10 weeks for maximum glucose
lowering effects
 Impact on weight: Neutral or
 Other Side Effects/Concerns:
-
Thyroid carcinoma
Acute pancreatitis
Gastroparesis
Narrow therapeutic index
medications
Loss
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; 2014.
Accessed Online: http://accesspharmacy.mhmedical.com.libproxy.siue.edu/ May 2015.
Take Home Points: GLP-1 receptor agonists
• Short-acting dosage formulations
• Exenatide: Take with a meal. Skip dose if usual meal missed
• Long-acting dosage formulations
• Common side effect: palpable nodule, erythema at injection site.
• No dependence on meals
• If dose is missed, take within 3 days of usual administration day . HAVE 2
ROUTINE ADHERENCE METHODS.
• Exenatide, Albiglutide: May need up to 30-60 minutes to prepare and
administer dose. Keep instructions with medication not in use or in a safe
location.
• Only use needles provided.
• Discontinue use 1 month before planning pregnancy.
DPP-4 Inhibitors
Take Home Points: DPP-4 inhibitors
 Efficacy: 0.7-1% A1c reduction
- Impact post-prandial glucose
- 4 weeks for maximum glucose
lowering effects
 Other Side Effects/Concerns:
- Acute pancreatitis
- Liver failure [alogliptin only]
 Impact on weight: Neutral
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; 2014.
Accessed Online: http://accesspharmacy.mhmedical.com.libproxy.siue.edu/ May 2015.
SGLT2 Inhibitors
Take Home Points: SGLT2 Inhibitors
 Efficacy: 0.7-1% A1c reduction
- Impacts fasting glucose
 Other Side Effects/Concerns:
- GFR < 30min/ml, ESRD , Dialysis
[Contraindicated]
 Impact on weight: Loss/Neutral
- GU infection
- Ketoacidosis
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; 2014.
Accessed Online: http://accesspharmacy.mhmedical.com.libproxy.siue.edu/ May 2015.
Insulin medications and delivery devices
Agent
Available as
V-Go® Insulin Delivery System
Prandial
BasalPrandial
Basal
NPH
Glargine U-100
Glargine U-300
Detemir
Lantus (Pen = Solostar)
Regular U-500
????
Levemir (Pen=FlexTouch)
Afrezza ® Inhaled Insulin
Regular
Humulin R
Novlooin R (??)
Aspart
Glulisine
Lispro
Novolog (Pen=???
Apidra (Pen=??)
Humalog (Pen=??)
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.
Picture from Valertiras. http://www.go-vgo.com/what-is-vgo. Accessed on March 2015
Picture from Sanofi-Aventis. https://www.afrezza.com. Accessed on May 2015
Picture from Valertiras. http://www.go-vgo.com/why-v-go. Accessed on May 2015
V-Go® Insulin Delivery System
• Simple, discrete way to administer insulin
• Do not have to travel with needles, pens,
or vials
• Maintenance Dose: Reach 50/50 split on
daily basal-bolus insulin dose
V-GO Start Guide. http://www.go-vgo.com/sites/default/files/upload/hcp-start-guide.pdf Accessed on May 2015
V-Go® Insulin Delivery System
V-GO Start Guide. http://www.go-vgo.com/sites/default/files/upload/hcp-start-guide.pdf Accessed on May 2015
23
Afrezza ® Inhaled Insulin
• Indication
• Age > 18 years old
• Type 1 or 2 DM
• Contraindications
• Chronic lung disease
(asthma, COPD)
• Precautions
(history of/at risk for)
• Lung cancer
• Diabetic ketoacidosis
• Hypokalemia
Afrezza ® Inhaled Insulin
 Efficacy: similar to prandial
insulin options
- Impact post-prandial glucose
- 3-5 days for maximum glucose
lowering effects
 Impact on weight: Weight Gain
 Other Side Effects/Concerns:
• Cough (common)
• Throat pain/irritation (common)
• Hypoglycemia (similar to prandial
insulin options)
• Fluid retention
Questions??