Diabetes Education and Management Program
Kentucky Clinic North
By: Sarah McCreary, Pharm.D. Candidate
JanuviaTM (sitagliptin) is a DPP-4 (dipeptidyl peptidase) inhibitor that works to increase the production of insulin from the pancreas and decrease the production of glucose from the liver. It may be used alone as an addition to lifestyle modifications (including diet and exercise) or it can be used in combination with metformin, glimepiride, metformin plus glimepiride, Avandia®, or Actos®. JanuviaTM is taken only once daily and may be taken with or without food. JanuviaTM lowers A1C by approximately 0.7 percent.
Adverse effects of JanuviaTM are rare but include a mild headache, upper respiratory infection, stuffy or runny nose, sore throat, or diarrhea. JanuviaTM has also been linked to a serious allergic reaction. This may be indicated by difficulty breathing, swelling of the tongue or mouth, or rash. Individuals experiencing any of these symptoms while taking JanuviaTM should stop taking it and contact a physician or an emergency department immediately.
ByettaTM (exenatide) is an analog of GLP-1 (glucagon-like peptide), a hormone that is necessary for the body’s use of food. Like JanuviaTM, ByettaTM also increases insulin production from the pancreas. Additionally, it slows gastric emptying and increases a person’s feeling of fullness. ByettaTM is used in combination with other medications, including metformin, Avandia®, Actos®, glipizide, glimepiride, and glyburide. ByettaTM can lower A1C by approximately 0.5 to 1 percent.
Due to its effect on a patient’s feeling of fullness, ByettaTM has been associated with weight loss. However, because ByettaTM is a relatively new product, long term data concerning maintenance of this weight loss is lacking. The longest period of time the effect has been studied is two years, and at that point, the average reduction from initial weight was 10 pounds. This was a progressive weight loss, as the average weight loss at week 30 was five pounds. Initial reductions in A1C were maintained at two years, with 50 percent of those studied achieving an A1C of less than or equal to 7 percent.
Unlike JanuviaTM, which is an oral tablet, ByettaTM is an injection that can be administered into the fatty tissue of the abdomen, thigh, or upper arm. It is injected twice daily within 60 minutes prior to breakfast and dinner, or the two main meals of the day as long as they are separated by at least six hours. ByettaTM is available in a pre-filled pen. Although they are initially refrigerated, ByettaTM pens may be stored at room temperature after first use. Pens should be discarded 30 days after initial use, even if some drug remains in the pen.
Adverse effects of ByettaTM are more significant than those associated with JanuviaTM and include nausea, vomiting, diarrhea, dizziness, headache and jitteriness. The gastrointestinal adverse effects (nausea, vomiting, and diarrhea) are most common and appear to be dose-related. They can be lessened by a gradual dose increase and with continued use. Low blood sugar reactions have been observed when ByettaTM is used in combination with drugs that cause low blood sugar, such as glipizide or glyburide. This is not observed when ByettaTM is used alone or in combination with metformin.
Recently, the FDA issued a warning linking ByettaTM to several confirmed cases of pancreatitis. In most cases, patients had other risk factors for pancreatitis, including gallstones, severely elevated triglycerides, or alcohol use. Patients taking ByettaTM are encouraged to contact their physician immediately if they experience severe abdominal pain with or without vomiting.
Currently, a long-acting formulation of ByettaTM that needs administration once weekly is under investigation. A recent study of the effects of the drug at 15 weeks showed a decrease in A1C by 1 to 2 percent. Also at 15 weeks, this long-acting form was associated with weight loss of five to 11 pounds with the higher dose group; patients receiving a lower dose experienced no change in weight. In addition, 86% of patients receiving the higher dose achieved an A1C less than or equal to 7 percent at 15 weeks. Long-acting ByettaTM was also associated with a lower rate of two-hour post-meal high blood sugar. The most frequent side effect was mild nausea. This formulation must be further evaluated by the FDA before it receives final approval for use.
Due to their modes of action, neither JanuviaTM nor ByettaTM can be used in patients with type 1 diabetes. Dose adjustments may be necessary in patients with kidney disease. Neither drug is recommended for use in pregnancy.
As new agents, ByettaTM and JanuviaTM are expensive medications. Each medicine is approximately $60 per month as covered by the UK health plan. ByettaTM requires a prior-authorization by your physician before it is covered at this price. As a comparison though, for patients not having any prescription insurance, average per-month prices (based on costs at local pharmacies) are $190 for JanuviaTM, $220 to $260 for ByettaTM, depending on the dose prescribed.
Both agents show promise for improvement in glycemic control; however, continued evaluation and longer-term studies are necessary to most accurately determine where these products fit best in treatment of diabetes. As with any medication, each of these new medicines has its own advantages and disadvantages. Therefore, it is important that both you and your diabetes care team discuss these issues before deciding to start treatment with either JanuviaTM or ByettaTM.
By: Billy Nettling, Pharm.D. Candidate
A) Hyperglycemia (high blood glucose) is common in a hospital setting. The stress your body is going through is enough to raise your blood glucose significantly. Certain medications being used to treat other conditions or an infection can also raise blood glucose. Hyperglycemia can be seen 1) in those patients with a history of diabetes, 2) in patients previously undiagnosed with diabetes, or 3) in situations solely due to stress on the body. A person’s blood glucose can revert back to someone without diabetes very soon before or very soon after being discharged from the hospital.
B) Your oral diabetes medications will most likely be held (not administered) during your stay. The reasons for this include 1) food habits at hospitals involve various eating times and frequent skipped meals, 2) the possible need for diagnostic procedures, and 3) the possible need for more aggressive therapy to control your glucose levels. Additional reasons regarding specific oral medications include:
C) Insulin is the treatment of choice for effectively controlling hyperglycemia in the hospital. More specifically, “intensive” insulin therapy is being used. This is carried out by one of two ways: 1) a combination of a rapid-acting insulin and a long-acting insulin given as subcutaneous (under the skin) injections; or 2) as an insulin drip/IV where rapid-acting insulin is being continuously infused at a slow rate. Recent studies show that the use of intensive insulin therapy in critically ill patients who have recently had a heart attack, and the surgical population, reduce the overall severity of the person’s admitting illness and chances of death*. These studies focused on keeping patients’ blood glucoses in a target pre-meal range of 80-130 mg/dL (tighter if someone is critically ill, 80-110 mg/dL) and 2-hour post-meal blood glucoses below 180 mg/dL in order to see these benefits.
D) Most hospitals, including the UK Chandler Hospital, have protocols in place regarding diabetes. They also have procedures to establish routine blood glucose checks, establish an effective meal plan and address hypoglycemia concerns.
E) Finally, you should receive education and counseling about your diabetes during your stay, and it is important that you understand your doctor’s plan for controlling your diabetes after you are discharged. Regardless of what may have taken place during your stay, it is always best to follow up with your primary diabetes care provider and possibly your diabetes educator soon (within one to four weeks) to assess your diabetes care.
*van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
Copyright ©2001 Massachusetts Medical Society. All rights reserved.
By: Billy Nettling, Pharm.D. Candidate
Shingles is usually seen as a rash on one side of the body, containing a cluster of small red spots. Shingles is caused by the same virus that causes chickenpox. Once you have had chickenpox, the virus can stay in your nervous system for many years. The virus may become active again later in life and give you shingles. Age and problems with the immune system may increase your chances of getting shingles.
Zostavax® contains a weakened form of the chickenpox virus, also known as the varicella-zoster virus. It helps the immune system protect against shingles or may help prevent the nerve pain that can follow shingles in some people. Zostavax® does not treat shingles once you have it. It is given as a single-dose subcutaneous (under the fatty tissue) injection.
You should know that Zostavax® does not protect everyone who gets the vaccine. The Shingles Prevention Study showed that Zostavax® reduced the overall incidence of shingles by 51 percent but did not completely prevent the disease from occurring. However, it was also shown that in those who still developed shingles that they experienced less associated pain.
The most common side effects that people in the clinical studies reported after receiving the vaccine included redness, pain, itching, swelling, warmth or bruising where the shot was given. Some incidences of headaches were also seen.
You should not get Zostavax® if you are allergic to neomycin or gelatin, have a weakened immune system, take high doses of steroids, or are pregnant or plan on becoming pregnant. Zostavax® is approved for individuals aged 60 and older for prevention of shingles. As always, you should talk to your primary healthcare provider beforehand to decide if Zostavax® is right for you.
The Zostavax® vaccine is covered by Medicare Part D prescription plans. You must bring a prescription from your prescriber to the pharmacy and have a pharmacist administer the vaccine in order to have the vaccine and administration covered by your Part D plan.
Zostavax® is currently available at the Kentucky Clinic Pharmacy. Vaccine administration is being offered Tuesdays through Thursdays from 9 to 11 a.m. and 1:30-4 p.m. Other times may be offered upon request by calling a Kentucky Clinic pharmacist at (859) 323-5855. For UK retirees, the co-pay for the vaccine is approximately $65. Medicare Advantage (patients’ Medicare Part B) through Humana will cover 80 percent of the administration cost. The remaining 20 percent that the patient would have to pay for the administration fee is approximately $4 and is billed by patient accounts at a later date. Without insurance, the vaccine costs around $228, with an additional $17 administration fee.
You have probably heard the saying “an ounce of prevention is worth a pound of cure.” This old adage is easy to apply to flu season. Influenza vaccines, as well as pneumococcal vaccines, are very important for people with chronic health problems like diabetes. The influenza vaccine protects against the flu, and the pneumococcal vaccine helps prevent pneumonia and other infections caused by the same bacteria as pneumonia. People with diabetes are three times more likely to die of the flu or pneumonia, but unfortunately only one-third of them get a flu or pneumonia shot.
Generally, every person with diabetes should get an annual flu shot. The American Diabetes Association recommends this for every person with diabetes over six months old. Because you are less likely to get the flu if the people around you do not have it, it is advisable to have people who live with someone with a chronic health condition get the flu shot also.
The great thing about the pneumonia (pneumococcal) vaccine is that you do not have to get it every year, and it can be administered the same day that you get a flu shot. At least one lifetime pneumonia vaccine is recommended by the American Diabetes Association for adult diabetes patients. Individuals who would need a revaccination, or a booster, are those that received their first vaccination younger than 65 years old, and it has been more than five years since that first pneumonia vaccine. Other individuals that should have a repeat pneumonia vaccine are those with chronic kidney disease or those with a compromised (weakened) immune state, such has those who have had a liver or kidney transplant.
Here are the flu shot schedules for patients seeing various providers in the clinics within UK Healthcare:
Family and Community Medicine: Patients may receive their flu shot during their regular business hours of 8 a.m. to 4:30 p.m. Monday through Friday. As a walk-in patient, you may have to wait 10 to 15 minutes. If you inquire about a pneumonia shot at that time, it will be administered at a prescriber’s order. On Wednesday afternoons from 2 to 4 p.m., there is likely less of a wait as there is a designated flu shot clinic with walk-ins still welcome and additional nursing staff to administer.
Internal Medicine: Walk-in hours for their patients Monday through Fridays from 9:00-11:30 a.m. and from 12:30-4:00 p.m. No appointment is necessary, however, shots will also be given during normally scheduled appointments when appropriate.
Women’s Health: Walk-in hours for their patients Monday through Friday from 9:00-11:00 AM or from 1:00-3:00 PM. Shots will also be given during scheduled appointments.
Kentucky Clinic South: Walk-in hours for their patients on Tuesdays, Wednesdays and Thursdays from 1:00-4:00 p.m. in their foyer. Shots will also be given during scheduled appointments.
By: Sarah McCreary, Pharm.D. Candidate
Depression is a real and possibly serious mental state that should be addressed in all people, but it carries additional risks in those with diabetes. A depressed mood can impact energy levels, appetite, motivation, and concentration. Not only can depression distract people from taking care of their health, but the anxiety and stress that accompany depression can actually raise blood glucose levels. Worsening diabetes can, in turn, lead to frustration and further depression. This cycle can trap patients and lead to a downward spiral of their health and well-being.
It is important to stay in tune with your mental health so that depression and anxiety can be diagnosed early and managed appropriately. Below are signs that you may have depression:
Depression warning signs:
If you ever have suicidal thoughts, if you are experiencing three or more of these symptoms, or if you have one or two symptoms but have felt this way for more than two weeks, contact your doctor right away. There are many effective, well-studied treatments for depression, and under your physician’s care, you can achieve emotional health and regain control of your diabetes.
To potentially avoid depression, consider these lifestyle modifications: increase your physical activity, get a good night’s rest as often as possible, and surround yourself with positive, encouraging people. These small changes can keep you feeling balanced and healthy, and can positively impact your diabetes care.
For more information, visit www.diabetes.org or www.behavioraldiabetes.org.
Carb Conscious Cuisine cookbook contains 150 low-carb, low-sugar recipes, complete with nutritional information, to encourage healthy eating habits in patients with diabetes as well as anyone looking to improve their eating habits! The College of Pharmacy has created this cookbook as a component of Operation Diabetes and is currently selling them for $12 each at the PharmacistCARE clinic (room K135). All proceeds will benefit the local American Diabetes Association. Everyone can benefit from eating healthy, so purchase one today in support of Operation Diabetes and the local American Diabetes Association!
Link to the National Diabetes Education Program for tips on diabetes friendly meals – that everyone can enjoy. http://ndep.nih.gov/diabetes/pubs/DiabetesFriendlyMeal.pdf
Properly managing diabetes requires a commitment to the daily mechanics of controlling blood sugar—testing regularly, balancing food with activity, counting carbohydrates, monitoring medications—as well as a commitment of emotional energy to stick with it. Some days it feels overwhelming.
UK HealthCare is considering forming a support group for patients with diabetes where members could help each other in an open and encouraging atmosphere by sharing their successes and struggles, plus learn about the latest treatment options and other resources available to help them cope.
If you or someone you know has diabetes, we want to hear from you. Send an e-mail to Geoffrey Blair at email@example.com to let us know if you think a diabetes support group would be beneficial and what programming the group could offer that would be most helpful to you.
to J. Carol Guinnup, Last Modified:
Wednesday, August 16, 2006
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