Standards of Medical Care in Diabetes 2017: Diabetes Medications

March 9, 2017 at 9:10 am | Posted in Health | 1 Comment
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Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

I recently reviewed updates to the American Diabetes Association’s (ADA) Standards of Care for 2017.  In this post, I’ll review Section 8 of the standard that talks about different medications for treating diabetes. I will also discuss some of the newer medications used to treat diabetes.

Type 1 Diabetes is always treated with insulin, either through multiple injections or an insulin pump. Type 2 Diabetes can be treated with oral medications (pills by mouth), injections, or both.  The ADA recommends that people with Type 2 diabetes start patients start with the pill metformin, as long as it safe for them to take it.    Taking metformin for a long time may lead to not getting enough Vitamin B12, stomach symptoms, and can affect how well the kidneys work (your care team will monitor your kidneys to be sure they are working properly).

If someone is taking one oral medication at the highest possible dose but their A1C is still not at goal, providers should consider adding additional medications:  another oral medication, long acting insulin (injection), or a non-insulin injectable medication called glucagon-like peptide 1 receptor agonists (GLP-1 receptor agonists).

Examples of GLP-receptor agonists are exenatide (Byetta), liraglutide (Victoza), and dulagultide (Trulicity).  These medications cause food to move through the stomach slower so people feel full sooner. This leads to less glucagon (another hormone made by the pancreas) being released after meals and lowers appetite, which helps with weight loss.  These medications need glucose to work, so there is little chance of hypoglycemia.  Side effects include nausea, vomiting and acute pancreatitis. They may also cause medullary thyroid cancer in animals. It should be noted that these medications are expensive.

People with poorly controlled diabetes and atherosclerotic cardiovascular disease (ASCVD aka heart disease) may benefit from a new medication called empagliflozin (Jardiance), a type of medication called SGLT-2 inhibitor.  These medications work by preventing the body from reabsorbing glucose. This lets more glucose leave the body through urine.  People may have lower blood sugar values after eating and lose some weight.  Studies show empagliflozin helped reduce deaths caused by heart attack, stroke, and cardiovascular disease.  Empagliflozin is the only SGLT-2 inhibitor with these results, but other medications are being studied (liraglutide [Victoza] may have the same results, but other GLP-1 receptor agonists are not used this way).  Potential side effects include hypoglycemia, low blood pressure, dizziness, urinary tract infection, needing to urinate a lot, and increased LDL and creatinine (a waste product filtered out by the kidneys).  Again, these medications are very costly.

There are many medications available for the treatment of diabetes. These standards are general recommendations for medical care.  Always discuss questions about your care plan with your healthcare provider.

Hypoglycemia Unawareness

November 7, 2013 at 1:05 pm | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NPWhen you have diabetes, regulating your blood sugar is a full time job without any time off for good behavior. Good control of your blood sugar is necessary to prevent potential complications but sometimes, regardless of how hard you’re working, it may seem that outside forces conspire to ruin your good control.  One of these issues can be hypoglycemia.

Hypoglycemia, or low blood sugar, is defined as a measured blood sugar that is less than 70 mg/dL. It may occur if you haven’t eaten enough, had unplanned strenuous activity, or taken too much medication. It may be accompanied by many symptoms including (but not limited to) feeling sweaty, shaky, extremely hungry, agitated, or experiencing blurry vision. If blood sugar reading is less than 70 mg/dL the recommendation is to have some fast acting carbohydrate like orange juice or glucose tablets at once and check again in about 15 minutes.

Hypoglycemia is a very serious complication of diabetes and left untreated can result in seizure, coma, and even death. When the sugar level gets too low, the body releases two hormones: glucagon and epinephrine.  Epinephrine is responsible for the early warnings signs of low blood sugar, such as the hunger and sweating mentioned earlier. It also signals the liver to start making more glucose. Glucagon signals the liver to release this stored glucose into the circulatory system to correct the low blood sugar. However, people living with diabetes may also experience another type of hypoglycemia that is extremely dangerous: hypoglycemia unawareness.  Someone with hypoglycemia unawareness does not feel the early symptoms of low blood sugar. People who have had diabetes for a long time are at risk for developing this condition, as are those with a history of frequent low blood sugars, frequent and extreme fluctuations in blood sugar values, and people who have very tightly controlled blood sugars.

The most important way to address this condition is AWARENESS. Check your blood sugar frequently so you’re aware of your patterns. Medication changes, activity changes, and illness are a few situations when checking your blood sugar can really pay off.  Sometimes it’s necessary to check in the middle of the night on a regular basis if nocturnal or fasting hypoglycemia is happening to you. This way you can identify the exact timing of the low and not only treat it, but take steps with your health care provider (HCP) to find a way to manage your medications or diet to avoid these episodes. Targets for your blood sugar goal may need to be adjusted. Not every person, especially the elderly or people with a history of severe hypoglycemia, needs an A1C between 6.5 and 7 so discuss this with your HCP.

It’s important to work with your CDE to identify any issues you may have with managing stress, diet factors, or even recognizing what your low blood sugar reaction is. I’ve told you some of the common symptoms, but no two people have the same experience when it comes to low blood sugar. I like to compare low blood sugar symptoms to poker: everyone has their own “tell.”  I’ve had people tell me “I know when I’m getting low. I see black spots/my tongue tingles/I get jumpy inside like I have bugs on me/I can’t hear clearly.”  This is also an opportunity to incorporate your support network (spouse, family, and friends) into the education about low blood sugars. Remember, some people get low so fast they’re not aware of the symptoms but a coworker or spouse can quickly pick up that they’re speaking without making any sense or sweating profusely. It’s also important to curtail your alcohol consumption when low blood sugars are an active problem.

I hope this information gives you the chance to start a conversation with your HCP about hypoglycemia AWARENESS so your full time job of diabetes management can be as successful as possible.

Diabetes ABCs: Intro

October 23, 2012 at 3:56 pm | Posted in Diabetes ABCs | 2 Comments
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Letter A

Today we’re launching a new blog series called Diabetes ABCs.  Our aim with this series is to provide a growing resource of common diabetes-related terms, define what they mean and explain what role they play in diabetes management.

We’ll feature two letters each week, starting with A and working through to Z.  This series will be constantly expanding, so if there’s a term you’d like us to cover (or one you think we left out) let us know either by leaving a comment or e-mailing us at:  diabetesviews@partners.org.

Without further ado, let’s launch right in with our first letter and term:

A1C

A1C (which is short for hemoglobin A1C or HbA1C) is a measurement of your average blood sugar for the past three months, which provides a “big picture” of how well your treatment plan is working.  Sugar in the blood sticks to a protein in red blood cells called hemoglobin, and the hemoglobin is said to be “glycated.”  The A1C test measures how much glycated hemoglobin there is in the blood.  Your care team can use these results to see how well blood sugars have been controlled and make adjustments in your treatment plan if needed.  An A1C less than 7% is usually the goal for a person with diabetes.  Remember though, your A1C is an average blood sugar and doesn’t replace daily blood sugar checks.

(Content reviewed by MGH Diabetes Center) 


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