Medication:
I've got too many tablets!
People with Type 2 Diabetes often receive multiple prescriptions from their doctors. These include tablets to lower blood sugar, blood pressure, cholesterol and drugs to reduce your risk of heart attacks and strokes. Many find this bewildering and have difficulty remembering whether they have taken their medication on a daily basis. Some choose to skip doses, especially since many of the drugs come with side effects.
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General advice on medication:
Know what medication you are taking, after all you shouldn't be swallowing anything without knowing what it does! You should be able to identify your tablets by name and remember the dose if possible. Carry a list of your medications in your purse; this is often useful when attending clinics.
Take your tablets regularly. If you have many tablets and tend to forget doses, obtain a dosset box from your pharmacist.
If a tablet disagrees with you let your doctor know.
Find out about the common side effects of your medication. Many treatments for high blood pressure require an occasional blood test to check on your kidney function. If you are on a 'Glitazone' for type 2 diabetes, you would be required to have a blood test for liver function. Remind your doctor when these tests are due.
Find out what targets you need to aim for. This is especially important with treatment of blood pressure,cholesterol & blood sugars
Medication prescribed to help lower blood sugar (Oral Hyperglycaemics)
Metformin
Metformin is a drug used to control type 2 diabetes. It is a member of a group of drugs known as biguanides, has been in use for many years and is known to be a safe and effective form of treatment.
How does it work?
Metformin works by reducing the amount of glucose produced by the liver and increasing the uptake of glucose by the cells of the body. This has the overall benefit of reducing blood glucose levels by 3-4 mmol/l. It does not increase how much insulin is made by the pancreas.
Metformin is also thought to help by lowering component of blood fats, that are often high in people with type 2 diabetes.
Metformin also decreases the appetite and helps you lose a few pounds in weight.
What are the benefits?
- Metformin does not cause weight gain and may indeed help with weight reduction by reducing appetite.
- There is some evidence of a lipid (fat) lowering effect
- does not cause release of insulin and therefore doesn't cause hypoglycaemia
What are the disadvantages?
The most difficult problem with Metformin is due to its effect on the gastrointestinal system. They cause a wide range of effects from a mild loss of appetite to nausea, vomiting, abdominal discomfort, cramps, flatulence and diarrhoea. Some people describe a temporary unpleasant or metallic taste when they start taking Metformin.
If you do experience stomach upset, it is desirable that you try to persevere with Metformin, even if you find you can only tolerate one or two tablets daily.
Many patients find these symptoms impossible to cope with and discontinue the tablets within days. Others find the effects tolerable and find they improve with time. Starting off with a small dose taken at meal times helps.
What is Lactic Acidosis?
Lactic acidosis, is a rare but dangerous side effect of Metformin. This is a serious condition where the cells of the body do not get enough oxygen to survive. It is caused by a build up of lactic acid in the blood. Most of the cases described have been in people whose kidneys were not working normally. Although rare, if lactic acidosis does occur, it may be fatal in up to half the cases.
Your doctor will monitor your kidney function and carry out blood tests from time to time.
There is no evidence that Metformin causes any damage to your kidneys or liver.
What are the warning signs of Lactic Acidosis?
- difficulty breathing – rapid rate of breathing
- feeling very weak and tired
- unusual muscle pains or discomfort
- vomiting
What precautions should I take?
If you have an illness that results in severe vomiting and diarrhoea and if your intake of fluids is reduced, it may be necessary to stop taking Metformin temporarily. It is also usual to stop Metformin if you develop a serious condition such as a heart attack, stroke or severe infection.
If you are going to have surgery or have specialised x-ray procedures that require injection of contrast agents, Metformin should be stopped temporarily.
What should I do if I intend to become pregnant?
Ideally you stop oral medications before planning your pregnancy. If pregnancy is confirmed unexpectedly you should stop taking Metformin as with other oral hypoglycaemic medications. Your doctor will probably change you over to insulin.
Who should not take Metformin?
Metformin is not recommended for the people with the following conditions
- kidney failure
- liver failure
- severe heart failure
- severe alcohol abuse
Sulphonylureas
The most commenly prescribed sulphonylurea is Gliclazide which belong to a class of drugs known as sulphonylureas. These tablets work by stimulating the pancreas gland to produce more insulin hormone, which lowers your blood glucose. They are frequently used in combination with Metformin or other tablets to control your diabetes.
How often do I take these Tablets?
Gliclazide is usually started in low dose taken about 20 minutes before breakfast. Higher doses are taken twice daily, before breakfast and before your evening meal.
Are there side effects?
Side effects of sulphonylureas are generally mild and infrequent and sometimes cause nausea or headache. Older drugs in this class were known to cause facial flushing after alcohol, but this does not occur with the newer agents. Sulphonylureas unfortunately have a tendency to promote weight gain. This can often be prevented by diet and exercise. They may occasionally cause hypoglycaemia (low blood sugar level). This is most likely to occur during the late morning if you have been physically active or if lunch is late. Symptoms would be faintness, sweating and disorientation. Eating a snack such as a couple of plain biscuitswill quickly make you feel better. It is important to be aware of this side effect when driving.
How long should I take this medication for?
It is important to be aware that diabetes treatment is lifelong and once you commence on tablets, you are likely to require some form of treatment for your diabetes always. Do not stop your tablets without prior discussion with your doctor. The natural course of type 2 diabetes unfortunately results in a slow loss of the ability of the pancreatic beta cells (insulin producing cells) to make insulin. A gradual loss of ‘efficacy’ is therefore usual with these tablets and many people require a progressive increase in the dose. Once the maximum dose has been reached your doctor may consider the addition of other tablets or a change to insulin therapy.
Glitazones
The Glitazones (or thiazolidenediones to give them their proper name) are a new class of drugs for the treatment of type 2 diabetes. They act by helping the body use the available amounts of insulin more effectively. In other words they make you more ‘sensitive’ to insulin or improve your ‘insulin sensitivity’. People with type 2 diabetes are often resistant to insulin, a phenomenon commonly referred to as ‘insulin resistance’. This is thought to be one of the reasons for high blood sugar levels in type 2 diabetes.
What are the available preperations?
There are currently two preparations available on prescription for people with type 2 diabetes.
- Rosiglitazone (AvandiaR Glaxo-Smith-Klein) – this is available in two strengths 4 mg and 8 mg
- Pioglitazone (ActosR Takeda Pharmaceuticals) – available in two strengths, 15 mg and 30 mg
What are the possible side effects?
If you take rosiglitazone or pioglitazone, it is important that you have your liver function tests (blood tests) done periodically. You should let your doctor know immediately if you have any of the following symptoms:
- Nausea or vomiting
- Severe loss of appetite
- Yellow discolouration of the eyes
- Passing dark-coloured (tea-coloured) urine.
- It is not uncommon to gain weight as these tablets can cause fluid retention. For this reason they may aggravate heart failure and you should not take these tablets if you are known to have heart failure. The fluid retention may give you swelling of the ankles.
- You may also develop a mild anemia, which could make you feel tired.
- If you are not yet menopausal but have had subfertility due to lack of ovulation, these drugs may result in ovulation which may increase your chance of a pregnancy.
Can these tablets cause hypoglycaemia?
Usually these compounds do not cause blood sugar levels to drop below the normal; however, this may occur since you are likely to be taking other tablets in conjunction with rosiglitazone or pioglitazone.
How will they work?
Do not expect dramatic results. The action of these drugs usually commences within 2-3 weeks and it may take up to 8 – 12 weeks for the maximum response.
What time of day should they be taken?
The timing of the dose is not important so long as you take them regularly.
Why can't I take these with insulin?
As yet, Glitazones are not licensed for use in combination with insulin. It is thought that when combined with Insulin, the glitazones may pose an increased risk of fluid retention and heart failure. Trials are currently under way and a license for combination therapy may be expected in the future.
Who should not take Glitazones?
People with the following conditions should not take Rosiglitazone or Pioglitazone
- Type 1 diabetes
- Pregnancy
- Heart failure
- Active liver disease
- If you are not currently pregnant but are contemplating pregnancy you should discuss this with your doctor.
New Inhaled Insulin - Insulin Exubera
What is Exubera
Insulin Exubera is a form of short acting insulin delivered by inhaler which is taken before meals. The trials have shown that insulin delivered by the inhaled route is as effective as the short acting insulin delivered by injection.
The insulin is inhaled as a dry powder which is absorbed via the lungs and thereby into the bloodstream.
Inhaled insulin does not at present substitute for long acting or basal insulin which may also be required for good control.
Is the effect sustained?
One of the many questions which researchers asked is ‘does inhaled insulin work long-term’ and ‘does it harm the lungs‘. Studies over a four year period have shown no deterioration in lung function as well as sustained efficacy. It must be understood that longer term safety data will only result from clinical use in patients.
The need to perform these studies explains why this product, which has been spoken of for many years, has taken so long to reach regulatory approval. Over three thousand patients have tried Exubera insulin in these clinical trials.
Is inhaled insulin only for type 1 diabetes?
No. It has been approved for use by those with Type 1 or Type 2 diabetes who require short acting insulin.
What doses will be available
Exubera is supplied in unit dose blisters containing 1 mg and 3 mg of human insulin. The recommended starting dose is based on this formula:
Body weight (kg) x 0.15 mg/kg = total daily dose in mg
The total daily dose is then divided into three pre-meal doses.
1 mg of Exubera is equivalent to 3 IU of human insulin injected subcutaneously (sc).
3 mg of Exubera is equivalent to 8 IU of human insulin sc.
The dosing is complex and 3 of the 1mg blisters does not equate to a 3 mg dose.
When should it be taken?
The dose should be inhaled within 10 minutes before the start of a meal.
Who is going to benefit from this insulin?
The target groups for inhaled insulin have not yet been clearly defined. However people who require assistance for injections, those who are ‘needle phobic’ and people who travel a lot may benefit.
What are the side effects?
During clinical studies it was observed that people treated with Exubera may have a mild to moderate cough which often disappeared with continued use. Small differences in lung function which occurred without symptoms, were also noted, though these changes were not progressive. Hypoglycaemia has been described and is more frequent in smokers in whom the use of this medication is contraindicated.
Who should not take Exubera?
Those with
- Poorly controlled or severe asthma
- Severe Chronic Obstructive Lung Disease (Chronic Bronchitis and Emphysema)
- Active smokers
- Pregnant women
Patients must not smoke during Exubera therapy and must have stopped smoking six months prior to initiating treatment. There is an increased risk of hypoglycaemia in smokers.
Can I get it on prescription?
At the time of writing Exubera has not been launched in the UK though the granting of a European drug licence is a promising start. The drug would also have to be approved by NICE - the National Institute for Clinical Excellence, which would look at the evidence from clinical trials and decide whether to recommend the preparation for use in the NHS. This advice will be based on clinical efficacy and safety as well as ‘cost-effectiveness’. Inhaled insulin will almost certainly be more expensive than conventional injected insulin. One of the questions NICE will examine, is ‘which patient groups would benefit from using inhaled insulin’.
Who will teach me how to use the inhaler?
As this is the first time this device will be used by healthcare professionals we anticipate that the manufacturing company Pfizer Ltd will provide education and support for use of the inhaler.
Is this going to be an expensive drug?
This has not been made public as yet.
When will it be available in the UK?
It is anticipated that Exubera will be available for prescribing in the UK from May 2006 though the launch date has yet to be confirmed.