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.

Are you newly diagnosed with diabetes, or struggling to control your blood sugar? If so, DMSE/S programs can help!

October 17, 2016 at 9:43 am | Posted in Announcements | Leave a comment
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Diabetes is a chronic, complex disease. Self management is key, but what does that even mean?  Where do you start? Self Management is the ‘taking of responsibility for one’s own behavior and well being.’   Living well with diabetes means you need to learn new skills and behaviors. This can seem overwhelming during an already stressful time.  DSME/S programs teach you the self management skills you need to truly thrive.

You will first see a nurse or nurse practitioner (who is often usually a Certified Diabetes Educator or CDE).  You will either continue to see that clinician by yourself or attend group classes with other people just like you. Group classes are a great way to learn and be supported by people who know what you’re going through. You are not alone! During appointments or classes, you will learn about important topics like nutrition, exercise, medications and more.  You will also set specific behavioral goals to work towards between each visit.

Research has shown that DSME/S works. It can lower your A1C and stop complications from happening or getting worse. Attending can also improve your quality of life and keep you out of the hospital. Major organizations like the American Diabetes Association, American Association of Diabetes Educators and the Academy of Nutrition and Dietetics all believe that everyone with diabetes should have DSME/S at some time in their life.

Mass General DSME/S programs are offered at Chelsea, Revere, Charlestown, Internal Medicine Associates, Diabetes Associates and Bulfinch Medical Group. For more information, contact Jen Searl at jsearl@partners.org.

Let’s Talk About Sex…No Really…Let’s Talk About It

March 8, 2013 at 11:30 am | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

I’m going to go out on a limb and make an assumption (despite what my father always told me):  Everybody reading this has seen at least one advertisement on TV or in a magazine about erectile dysfunction and the medications available for treatment. In fact, sometimes I look at my bath tub and just chuckle. But that’s not true for everyone. These ads refer to a topic that is no laughing matter for people living with diabetes who have sexual dysfunction.

Sexual dysfunction affects both men and women so I want to break this down for you. Erectile dysfunction (ED), or impotence, is defined as the inability to achieve or maintain an erection that is suitable for sexual intercourse. Poorly controlled blood sugars can cause damage to the blood vessels and nerves in the genital area that can lead to ED.  Over 30 million men are affected by ED, with somewhere between 35%-75% of men with diabetes affected at some level across the lifespan. There are many potential reasons for ED, including but not limited to medication side effects, fatigue, stress, poorly controlled blood sugars, excessive alcohol intake, increased age, increased weight, and high blood pressure.

Another potential culprit in ED may be low testosterone levels. Testosterone is a hormone responsible for the development of male reproductive tissue.  This condition is twice as likely to occur in men with poorly controlled diabetes. Low testosterone may present with complaints of decreased libido, depression, fatigue and decreased energy, and a decrease in lean body mass. Testosterone levels can be checked by a blood test if your health care provider thinks this is indicated. A treatment plan can then be established if necessary.

One very important treatment for ED is attaining better control of your blood sugar. Oral medications are another available treatment option, but there are certain medical conditions where the use of these agents is contraindicated.  Men with heart disease or on certain cardiac or blood pressure (antihypertensive) medications may have very serious low blood pressure if they take any of these agents, so it is important to discuss your medications with your health care provider. Men that are able to use ED medications may have less serious side effects such as headache, facial flushing, back pain, and nasal congestion. These side effects are related to how these medications work.  They are vasodilators, which means they cause a systemic effect to all the body’s blood vessels so they open more fully. Some non-medication treatment options for ED include assistive devices such as vacuum pumps, local injections, and in some cases surgical intervention for penile implants.  Talk to your health care provider about what treatment options are best for you.

Women with diabetes may also have symptoms of sexual dysfunction. Women may experience symptoms such as decreased libido, vaginal dryness, and decreased orgasmic ability again due to damage to blood vessels and nerve endings in the genital area. Elevated blood sugars may cause vaginal yeast infections and urinary tract infections that compound vaginal dryness and make sexual intercourse uncomfortable.  The possible treatment  modalities in this case also include achieving better blood sugar control and discussing with your health care provider  if prescription or over the counter medications are indicated.  Once you and your health care provider discuss your issues with sexual dysfunction, they may refer you to another provider to assist in developing a treatment plan. Men may benefit from an evaluation with a urologist and women may require an evaluation with a gynecologist.

The key to dealing with a problem, any problem, is discussing it with your health care provider. Talking about sex isn’t easy. It may be hard for you and your partner to admit there is a problem, and it may be embarrassing to discuss with your provider (especially if they are a member of the opposite sex). I want you to think that a problem in the bedroom is a problem just like numbness in your toes or hypoglycemia with exercise. You need to let your provider know so you can get help.  I will share with you that as a provider it can also be hard to ask about sex. I have no trouble asking Are your toes numb? or Are you checking your blood sugar before driving? But I stop and think a second before I ask if there are any problems in your sex life. I want to make you feel comfortable enough with me to talk about this because sexual health is an important part of our general health— and I don’t want to miss any part of you when you come to see me. So what do you think? Ready to talk? I hope so.

Diabetes ABCs: V

January 2, 2013 at 1:00 pm | Posted in Diabetes ABCs | Leave a comment
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Victoza
By Eileen B. Wyner, NP
Bulfinch Medical Group

V

Victoza is a new medication in the class called glucagon-like peptide-1 (GLP-1). This is an injectable medication used for the treatment of Type 2 Diabetes taken once a day, with or without food. It works by helping the pancreas to release the right amount of insulin when blood sugar levels are high. It also slows the emptying of the stomach and may decrease appetite and cause weight loss.

Diabetes ABCs: S

December 24, 2012 at 10:00 am | Posted in Diabetes ABCs | Leave a comment
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Sulfonylureas
By Eileen B. Wyner, NP
Bulfinch Medical Group

S

Sulfonylureas are a class of medications used to lower blood sugar in people with Type 2 Diabetes.  These oral agents increase the production of insulin from the beta cells of the pancreas. Sulfonylureas are typically taken once or twice daily before meals and can be used alone or in combination with insulin or other Type 2 Diabetes oral medications. This class of medications may cause severe hypoglycemia if taken incorrectly.

About Diabetes Medications

March 15, 2012 at 9:00 am | Posted in Health | 1 Comment
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By Deanna Wrubleski, Pharmacy StudentDeanna W
University of Rhode Island

The list of medications used to treat Diabetes is long, and is likely to grow even longer as new medications are developed. As a person with Type II Diabetes, you may be on one, two, or even three of these medications (or more!) and it’s easy to become overwhelmed. It’s good to know how your medications work and what they’re doing to help lower your blood glucose.

Diabetes medications work in four major ways:

  1. Increase insulin production and release from the pancreas
  2. Increase insulin sensitivity
  3. Decrease glucose made by the liver
  4. Slow digestion of carbohydrates into glucose

Medications that work by increasing the insulin made and released by the pancreas include glipizide (Glucotrol), glyburide (Diabeta), nateglinide (Starlix), repaglinide (Prandin), sitagliptan (Januvia), exanatide (Byetta), and liraglutide (Victoza). Since they increase insulin, these medications can cause hypoglycemia as a side effect.  To be on the safe side, make sure you recognize the symptoms of hypoglycemia and know how to treat it.  Over time, these medications may stop working as well as they once did.  After years of making large amounts of insulin to make up for the body’s resistance, the cells in the pancreas become overworked and the pancreas slowly loses its ability to make insulin.

Medications that work by increasing insulin sensitivity include metformin (Glucophage), pioglitazone (Actos), and rosiglitazone (Avandia).  Basically, these medications make the insulin the body already produces work better. People with Type II Diabetes actually produce more insulin than the average person, but resistance causes the insulin to have less of an effect. That is why medications like these are useful for lowering blood glucose.

Medications that work by decreasing the glucose made by the liver include metformin (Glucophage), sitagliptan (Januvia), exanatide (Byetta), and liraglutide (Victoza). If you were starving without any food, it would be good for your liver to make glucose, since your brain needs it to survive. But it’s unnecessary (and even harmful) for the liver to do this if your blood glucose is already high. So for people with Diabetes, telling the liver to “slow down” making glucose is beneficial.

Finally, the two medications that slow the digestion of carbohydrates into glucose are acarbose (Precose) and miglitol (Glyset). Slowing down the digestion of carbohydrates means less glucose is absorbed, which helps prevent a big jump in blood sugar after eating. Keep in mind, though, that these medications only work when taken with a meal, and shouldn’t be taken if a meal is skipped. Also, people taking these medications should always have glucose tablets on hand to treat hypoglycemia. Sucrose, which is what table sugar and most sugary snacks and beverages are made with, won’t treat hypoglycemia in people taking these medications as sucrose is a carbohydrate that still has to be broken down into glucose to be absorbed.


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