Actos

This will be the first time I'm using the brand name for a medication in my post. If you remember from a few weeks ago, I told you that Actos is now available as a generic called pioglitazone. Since the generic is so new and most of you will still know this drug by the name Actos, I'm going to make things easier and call it by its brand name. Actos is one of two drugs in the category known as the TZDs. I won't bother spelling out the name of the class for you here, because quite frankly it is just a mouthful, but if you are curious you can read my previous post about it here.

How does it lower blood sugar: Actos lowers the amount of glucose in your blood by making your cells more sensitive to insulin. As a reminder, insulin is the hormone that opens the door to your cell, allowing glucose in. Think of insulin as a butler and the glucose in your blood as guests wanting to get into the house (cell). In type 2 diabetes, your cells do not recognize insulin very well (the butler is left out in the cold, and so are the guests!). But Actos helps the cell recognize the insulin so that it can do its job, kind of like the maid opening the door for the butler (forgive my pathetic analogy, but I bet you'll remember how Actos works now!).

Another interesting thing about Actos is how it affects your fat cells. We have two types of fat in our bodies - subcutaneous and visceral. Subcutaneous fat exists right underneath your skin. Visceral fat is deeper in your body and surrounds your organs (liver, stomach, and even streaking in your muscles). This visceral fat is the "bad" kind of fat - big amounts of it are related to type 2 diabetes and heart disease. Visceral fat cells are less sensitive to insulin, and subcutaneous fat cells are more sensitive. Actos actually cause your body to produce less visceral fat cells and more subcutaneous fat cells! This means that more glucose can be pulled out of your blood!

The effect on your numbers: Actos can lower your A1c by 1-2% (an A1c of 9.5 could go down to 8.5 or 7.5 with Actos). However, it does take at least 4-8 weeks to see an affect on your A1c, and it might even take up to 16 weeks to see the full effectiveness of the medicine. What's the other number that Actos can affect? Weight. Actos can cause weight gain of about 12 pounds, or more depending upon what other diabetic medications you are taking.

Dosing: Actos is usually started at a dose of 15 mg once daily. You can take Actos with or without food (Actos does not cause hypoglycemia like some of the meds I've already talked about!). If your A1c does not come down far enough after 6-8 weeks, then we will increase the dose or try another medication. Doses can be increased up to a maximum of 45 mg taken once daily. However, doses over 30 mg are not usually effective and may cause more side effects.

Side effects: So what are the side effects of Actos? I've already mentioned one - weight gain. This is due mainly to a buildup of fluid in your body (usually legs and feet) called edema. Fortunately this stabilizes after you've been on Actos for about six months, but your doctor might put you on a "water pill" to help get that extra fluid out of your body. Other side effects that you might notice when on Actos are headache, upper respiratory infection, and bone fracture.

A unique side effect of Actos is that it can cause ovulation and menstruation in women that previously were not ovulating or menstruating. This includes women who are premenopausal and those with polycystic ovary syndrome (PCOS). It is important that women taking Actos are aware of this because Actos should not be taken when pregnant, so doctors will advise them to take adequate precautions.

Who should not take Actos: The most major precaution with Actos has to do with the heart. If you have congestive heart failure, talk to your doctor about whether or not Actos is right for you. Actos can cause fluid to build up in the lungs, or even lead to heart failure, in patients with a bad heart. This has found to be even more of a concern with the other drug in this class (Avandia) that I will talk about next week, but it is important to know about Actos. Generally we can control this fluid buildup by adding a "water pill" and decreasing your Actos dose, but sometimes we will have to try other medications instead of Actos.

Actos can cause liver toxicity, so patients with liver problems should not take Actos. Actos is not effective for patients with type 1 diabetes or those type 2 diabetics that are no longer producing their own insulin. Due to a risk of potential bladder cancer caused by long periods on Actos and high doses, patients with active or prior bladder cancer should not take this medicine.

Drug interactions: It is possible that Actos may decrease the effectiveness of oral birth control. Other medications that can interact with Actos include the cholesterol medications Lipitor and gemfibrozil, the antibiotic ketoconazole, and thyroid medications. As always, this is not the full list and every patient is different, so consult with your local doctor and pharmacist regarding other medications that you are taking.

Monitoring: As always, you should be checking your blood sugars on a daily basis when on Actos. Your doctor will also be checking your A1c to see how your diabetes is being controlled. Also, you can expect liver tests when taking Actos, to make sure that it is not causing problems. We will also watch for fluid buildup in your legs and feet and will monitor bone health, especially in elderly women, to try to prevent fractures.

Place in therapy for diabetes: Currently Actos is considered the second step for a patient after diet, exercise, and metformin have failed. We will usually give metformin a trial run for three months and then switch to either insulin, one of the sulfonylureas that I've already talked about, or a TZD like Actos. Actos is considered for patients that have trouble with low blood sugars, because the sulfonylureas and insulin cause more hypoglycemia. And now that Actos is generic, it will soon become a cost-effective choice. However, be aware that up to 25% of patients not see any effect on their A1c from Actos, so we might have to try another medication.

If you'd like to read more about Actos (and see a really cool video showing how it works!), visit the manufacturer's website here.

Next week I will talk about the other TZD. This is the medication that you might be seeing on television commercials, and not for a good reason! So come back next week and I will break down the rumors and truths about Avandia.

As always, if you have any questions concerning type 2 diabetes and medications, feel free to leave a comment or email me at DrK@solutionsfort2diabetes.com
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As a disclaimer, I am your “virtual” pharmacist, here to provide you with information and answers to questions. However, I am not your local pharmacist and could, in no way, be aware of your specific medical needs. Remember to always check with your medical provider and pharmacist before stopping or starting any new medications. My posts are based on general pharmacy principles and should not considered as your “first opinion” when it comes to your health. Please consult with your doctor and pharmacist about anything regarding your health.

Glipizide

Today I'm going to talk about another diabetes medication in the same class as glyburide. I'd like to introduce you to glipizide, also known by the brand name Glucotrol. This is a 'younger' student in the class (and when I say younger, that is only relative to the 'older' drug glyburide - glyburide was developed in 1966 and glipizide in 1984). If the names are starting to get confusing, that's not a surprise - all of the most common sulfonylureas used today for diabetes start with the letters "gl".

If you want a refresher on sulfonylureas, and the other classes of diabetes medications, you can find out more in my previous post here.

How does it lower blood sugar: Like the other sulfonylureas, glipizide lowers your blood sugar by increasing the amount of insulin that your pancreas puts into your blood. Insulin is put into the blood so that it can "push" sugar into your cells and out of your bloodstream. To a small extent, glipizide may make your cells more sensitive to insulin, but mostly glipizide just increases the amount of available insulin. As I discussed last week, since the pancreas sometimes stops producing insulin as the disease gets worse, glipizide might not always work for you.

The effect on your numbers: Glipizide may lower your A1c by 1-2% (so if your starting A1c was 11, it might go down to 10 or 9 after being on glipizide). Glipizide may cause weight gain.

Dosing: We generally start patients at a dose of 5 mg once daily and then after some time this can be increased, up to a maximum of 40 mg daily. Glipizide also comes in an extended release tablet, which means that the medication will release into your body more slowly. The extended release glipizide cannot be cut, chewed, or crushed.
Just as I mentioned with glyburide, glipizide must be taken with food. If you take glipizide on an empty stomach, your blood sugar will drop and could get dangerously low. If you want to read more about low blood sugar (hypoglycemia) including what it feels like and how to treat it, please visit this link.

Side effects: The major side effects of glipizide are low blood sugar and weight gain. Aside from these, you may have some nausea and diarrhea, which can be avoided by using a lower dosage of glipizide. Some patients may get a rash, itching, and sun sensitivity (sunburning easily) from glipizide. Glipizide does not stay in the body quite as long as glyburide does, so if you had side effects with glyburide, you might not have the same side effects with glipizide.

Who should not take glipizide: If you have a sulfa allergy, you should not take glipizide. If your diet is inconsistent or you have a history of low blood sugar problems, you should probably not take glipizide because of the chance of hypoglycemia. Pregnant and breastfeeding women should not use glipizide. Those with severe liver or kidney failure should also not take glipizide.

Drug interactions: Glipizide will make your body not tolerate alcohol very well, so do not drink alcohol while on glipizide. Side effects of drinking alcohol while on glipizide include nausea, flushing of the skin, vomiting, shortness of breath, and very low blood pressure. But the most important thing that happens is that it can increase the effect of low blood sugar, which can be very dangerous.

Other medications that can interact with glipizide and make it work better or worse are certain blood pressure medications, diuretics (“water pills”), blood thinners, salicylates (like aspirin), and certain antidepressants. Remember, check with your local pharmacist or doctor before starting any new medications, both prescription and over-the-counter. And make sure your pharmacy is aware of all medications that you take so that your pharmacist can check for drug interactions when you come in with a prescription.

Monitoring: You will have to monitor your blood sugars throughout the day. Watch for signs of low blood sugar (feeling like your heart is racing, headache, confusion, increased sweating, hunger, shakiness, tingling in the mouth, and a feeling of anxiety). If you start to feel any of these, check your blood sugar immediately. If it is too low, have a 15 gram carb snack followed soon by a meal of complex carbohydrates.

Place in therapy for diabetes: Glipizide is usually given to a patient when metformin doesn't work fast enough, or if they can't take metformin. Glyburide and glipizide are both about the same price and work the same way, so it is up to your doctor as far as which one you should try first. After some time, your pancreas might stop making insulin, so your doctor will need to choose another medication.

If you want to read more about glipizide, you can learn about it here.

Next week I will discuss the last of the commonly used medications in the class of sulfonylureas. You won't want to miss it!

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As a disclaimer, I am your "virtual" pharmacist, here to provide you with information and answers to questions. However, I am not your local pharmacist and could, in no way, be aware of your specific medical needs. Remember to always check with your medical provider and pharmacist before stopping or starting any new medications. My posts are based on general pharmacy principles and should not considered as your "first opinion" when it comes to your health. Please consult with your doctor and pharmacist about anything regarding your health.

Glyburide

So the last time you were at your doctor's office, they told you that you have diabetes and started you on metformin.  You went home and started taking it, and tried to improve your diet and exercise.  Now you are back in the clinic for your first lab tests.  The doctor checks your A1c and it is still not to where it needs to be (less than 7% is the goal).  So what do we do?  Since so many problems can come from diabetes that is not under control, your doctor is going to want to start you on another medication quickly to bring your numbers down faster.

Which medication will they choose?  The American Diabetes Association, as well as other medical organizations, have come up with a "roadmap" of how to treat diabetes using medication.  From my blog last week on diabetes, you know that metformin, combined with lifestyle changes in diet and exercise, is our starting point on the journey.  If your A1c is not low enough at the next visit, doctors have three main options: insulin, sulfonylureas, or TZDs.  If you need a refresher on these categories, or if you are tuning into my blogs for the first time, please read my blog on the different classes of diabetes medications here.

Each option has its own pros and cons, but I'm going to start with the sulfonylureas, since they are the least expensive and most common options, second to metformin.  The first sulfonylurea I'll be covering is glyburide, which also goes by brand names DiaBeta, Micronase, and Glynase.

How does it lower blood sugar: Glyburide helps your body release insulin into the blood.  Remember, insulin is the hormone in your body that helps take the sugar out of your blood and puts it into your cells.  So glyburide puts the insulin where it needs to be - in the blood where your sugars are.  In a very small way, glyburide also makes your cells more sensitive to insulin ("opening the door of the cell" for sugar to enter), but this is not the most consistent way that glyburide works.  Unfortunately, as type 2 diabetes progresses, the body sometimes can no longer make its own insulin.  At that point, glyburide is no longer effective because there is no more insulin there to "move."  But in newly diagnosed type 2 diabetics, glyburide can be very effective.

The effect on your numbers: Like metformin, glyburide also lowers your A1c by about 1 - 2% (a patient with an A1c of 9 could go down to an A1c of 8 or 7 when on glyburide).  Glyburide really doesn't seem to lower a patient's cholesterol levels, which was a benefit that we saw with metformin.

Dosing: Glyburide is usually taken once daily, in doses from 2.5 to 20 mg.  Usually patients are started at 2.5 or 5 mg daily and then increased as needed.  Just like with metformin, your doctor can change your dose every 1-2 weeks if needed.  Glyburide should always be taken with the first meal of the day (within about 30 minutes before).  It is important to always take glyburide with food because otherwise the medication will cause your blood sugar to drop too low (hypoglycemia).  So it's important to state again, always take glyburide with food.

Side effects: Hypoglycemia (dangerously low blood sugar) is one of the most dangerous side effects.  Weight gain can also be a possibility with glyburide (obviously not ideal in most diabetics).  Glyburide is the medication in this class with the most likelihood of these side effects, since it takes the longest to leave your body once it is in there.  The other side effects you might have from glyburide are a feeling of stomach fullness (as if you've just finished eating a big meal), heartburn, rashes/itching, and nausea.  Very rarely, glyburide can cause liver problems (hepatitis).

Who should not take glyburide: Any patients with a "sulfa" allergy should not take glyburide, or any other sulfonylureas (which I will be covering in the next few weeks), because they contain the thing that you are allergic to.  Because of the risk of low blood sugar if not taken correctly, anyone that has a very inconsistent diet or has a history of low blood sugar episodes might not be an ideal candidate for this medicine.  Glyburide should not be used in any patient that is pregnant or breastfeeding.  Also, if you have severe liver or kidney problems, your doctor will avoid using this class of medications.

Drug interactions: The most important thing that I want to stress here is that alcohol must be avoided when taking glyburide.  A simplified way to look at it is that glyburide causes your body to not tolerate alcohol.  You could experience side effects such as nausea, flushing of the skin, vomiting, shortness of breath, and very low blood pressure.   But the most important thing that happens is that it can increase the effect of low blood sugar, which can be very dangerous.  Other medications that can interact with glyburide and make it work better or worse are certain blood pressure medications, diuretics ("water pills"), blood thinners, salicylates (like aspirin), and certain antidepressants.  Remember, check with your local pharmacist or doctor before starting any new medications, both prescription and over-the-counter.  And make sure your pharmacy is aware of all medications that you take so that your pharmacist can check for drug interactions when you come in with a prescription.

Monitoring: Just like with metformin, your doctor is going to monitor your A1c, and you will need to monitor your blood sugar levels daily.  Because of the chance of low blood sugars with this medication, you need to be even more consistent with monitoring your blood sugars, and watching if they are too low.  Signs of low blood sugar include feeling like your heart is racing, headache, confusion, increased sweating, hunger, shakiness, tingling in the mouth, and a feeling of anxiety.

If you start to experience any of these, or if you just don't "feel quite right," check your blood sugar immediately.  You will need to have a snack available right away to eat that contains at least 15 grams of carbohydrates, in order to raise your blood sugar to a safe level immediately.  A list of these types of snacks, as well as other information about hypoglycemia can be found here.  I've copied the list over for your reference, to make it easier:

• 4 oz (1/2 cup) of juice or regular soda
• 2 tablespoons of raisins
• 4 or 5 saltine crackers
• 4 teaspoons of sugar
• 1 tablespoon of honey or corn syrup

Choose what will work for you.  Read labels and find something that is appropriate for your  lifestyle.  It needs to be something that is readily accessible by anyone, especially if you are not feeling well enough to get to it.  Remember, regular soda is needed here, not diet.  When we are trying to raise blood sugar quickly, we need to have sugar, not something that is "diabetes friendly."

Once you've had your 15 grams of carbs, you still need to eat a meal containing complex carbs that will help your body get back up to a normal level.  The foods I just mentioned are simple carbohydrates - your body processes them quickly, your blood sugars rise quickly, and then they are gone.  Complex carbs are things like vegetables, brown rice, whole grain breads, and wheat pasta.  Don't stop with just the 15 gram snack or you might be in the same low blood sugar situation within a few hours.

Place in therapy for diabetes: Glyburide is considered one of the first or second choices for treating type 2 diabetics (second usually to metformin).  This is because it is inexpensive, not a shot like insulin is, and only has to be taken once or twice a day.  It is important to mention that some patients just don't see any results with glyburide, or the other medications in this class, so we try it and then have to switch to something else.  As diabetes progresses and your body changes, sometimes glyburide (and any of the other diabetes medications taken by mouth) does not work as well.  About 5-10% of diabetics every year have this happen.  If it does, we can sometimes switch you to another medication within the same class.  Next week I will be talking about another one within this class, so don't miss it!

In case you are curious and want to know more about glyburide, you can find more information here.

If this turns out to not be the right drug for you, don't worry.  As you will see, we have plenty of options.  And as Phil has talked about, you do not have to be a "victim" of diabetes.  You can make changes in your own life that will help to fight back the disease.  They won't cure it, but they will make our medications much more effective, and will keep you living the healthy and happy life that you deserve.  I'm thinking about you, each and every one of you, and wishing you all the best in your fight!  Keep up the good work!

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As a disclaimer, I am your "virtual" pharmacist, here to provide you with information and answers to questions.  However, I am not your local pharmacist and could, in no way, be aware of your specific medical needs.  Remember to always check with your medical provider and pharmacist before stopping or starting any new medications.  My posts are based on general pharmacy principles and should not considered as your "first opinion" when it comes to your health.  Please consult with your doctor and pharmacist about anything regarding your health.