Glimepiride

We'll be finishing up the sulfonylurea class of medications today with the drug glimepiride. There are a few other drugs in the category, but they are so rarely used because of their side effects, so I'm only going to list them for your knowledge. I've never seen them used in my practice. If you do have questions on them, please feel free to message me in the comments below. The other sulfonylureas are:

• acetohexamide (brand name Dymelor)
• chlorpropamide (brand name Diabinese)
• tolazamide (brand name Tolinase)
• tolbutamide (brand name Orinase)

But back to glimepiride, otherwise known by the brand name Amaryl. Yes, it is available as a generic.
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, glimepiride lowers your blood sugar by increasing the amount of insulin that your pancreas puts into your blood. Remember, insulin is the hormone that is put into the blood to "push" sugar into your cells and out of your bloodstream - making your blood sugar lower!

The effect on your numbers: Glimepiride may lower your A1c by 1-2% (so if your starting A1c was 12, it might go down to 11 or 10 after being on glimepiride). Glimepiride is known to cause some weight gain.

Dosing: The starting dose for glimepiride is generally 1 or 2 mg once daily with breakfast or the first meal of the day. We can increase this dose, usually every 1 to 2 weeks, up to a maximum of 8 mg daily. Glimepiride works in your body for 24 hours, so it really only needs to be taken once a day - a good thing because who wants to remember more pills!

As with all of the other meds in this class, glimepiride must be taken with food to avoid hypoglycemia (dangerously low blood sugar). If you want to read more about hypoglycemia, including what it feels like and how to treat it, please visit this link.

Side effects: The most common side effect of glimepiride is hypoglycemia. We want your blood sugar to be a certain level, not too high and not too low, because too low can cause many problems (remember, sugar is energy for your body). The lower your fasting blood sugar is before you start taking glimepiride for the first time, the more likely you will be to have hypoglycemia when on the medication. Also, if you exercise frequently or lose a lot of weight, you may find that you start having too low of blood sugars when on glimepiride. And no, I am not telling you that so that you don't exercise or lose weight - please know that a healthy weight is what I want for you! But know that if you lose the weight and are consistent with your exercise, your doctor might need to change your med at some point.

Who should not take glimepiride: If you have a sulfa allergy, you should not take glimepiride because it contains a sulfa molecule. If your diet is inconsistent or you have a history of low blood sugars, you should probably not take glimepiride because of the chance of hypoglycemia. If you are pregnant, breastfeeding, or have kidney or liver problems, your doctor will probably use a different medication other than glimepiride for your diabetes.

Drug interactions: Some medications that can interact with glimepiride and make it work better or worse include certain blood pressure medications, diuretics (“water pills”), blood thinners, salicylates (like aspirin), and certain antidepressants. You should not drink alcohol when taking this medication.

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: As always, you will have to check your blood sugars daily while on glimepiride. Your doctor will need to check your A1c once or twice a year at least - this tells them how well your medications and daily habits are working to treat your diabetes.

Place in therapy for diabetes: Glimepiride is usually used when metformin has not worked or is not an option for you. When type 2 diabetes gets severe or progresses, sometimes your body no longer produces insulin, so then glimepiride might not be the option for you.

If you would like to read more about glimepiride, you can do so here.

Next week we will continue into a new class of medications. Aren't you excited? I am! Stay tuned!
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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.

A New Generic!

I won't be fully discussing Actos for a few more weeks, but I wanted to let you know that it is now available as a generic! What does this mean? Lower price for the same medicine!

You can access the article here.

The generic for Actos, pioglitazone, has now been approved by the Food and Drug Administration (FDA) for sale within the United States. You see, when medications first come out for use in the US, they can only be produced by one company. The company that spent the money developing the drug and applying for approval by the FDA is allowed to market their drug exclusively for a certain amount of time, under a brand name. After a certain number of years, this patent expires and other companies can apply to the FDA for approval of their generics to the original drug.

Many patients do not have a full understanding of generic medications. I have many customers that will only buy brand name medications because their belief is that generics are inferior products. And I can understand the confusion. Think about it, you buy store brand facial tissue and it doesn't ever seem to hold up as well as Kleenex, does it? Generic cereal never tastes the same as the brand name product, right? In these cases, generic sometimes signals "low quality."

This isn't the case with medications. The FDA requires all generic medications to be held to as high of standards as brand name medications. They go through an approval process that requires manufacturers to prove that the drug in the generic product is the same as in the name brand. The active ingredient, the "drug," must be identical chemically in both products.

The next time you are in the store, pick up a box of Aleve and a box of its generic "naproxen". Turn to the part where it lists the active ingredients. On both, you will find the words "naproxen sodium 220 mg." This is the main ingredient, the drug that is helping with your pain. Your generic facial tissue company can use as much or little paper to make their product as they want, but if a box says it is generic for Aleve, it will have 220 mg of naproxen in it.

You will notice that the inactive ingredients might be a bit different between the two boxes. Inactive ingredients are basically just fillers - they give the tablet its shape, color, and form. They are considered inactive because they do not do anything to change how the active ingredient, the naproxen in this case, works. Each company uses different fillers to make their tablets, but they don't affect how the medicine works. If they did, they would not be approved by the FDA as a "generic" product.

The most important thing to know is that all generics, before being sold in the US, have to be proven to be equivalent to the original brand name product. They can't work "almost as well" as the original - the makers of the generic have to show that they work the same way as the original. The same amount of the drug must reach the patient's blood in the same amount of time in both the name brand and generic for it to be considered equivalent. The generic has to be just as strong, pure, and stable (meaning it does not expire any sooner than the brand name medicine sitting next to it in your medicine cabinet) as the original brand name drug, or it will not be approved.
If you want to read more about what the FDA has to say about generic medications and the approval process, there is a wonderful article on their website here.

What I like to remind people is that generics have been around for many years. When you look at a list of the top 200 medications that were prescribed this year, the vast majority of them are generic medications. Chances are, you are currently taking a generic medication on a daily basis and have probably thought nothing of it. Metformin, our drug of choice for type 2 diabetics, is a generic. Most blood pressure medications that we commonly use are generic (lisinopril, atenolol, metoprolol, amlodipine - any sound familiar? all generics). Cholesterol medications are usually generic too (statins such as simvastatin, pravastatin, lovastatin, and the newest generic atorvastatin).

Most insurance companies won't cover a brand name medication once a generic is available, unless your doctor fills out some paperwork stating why the brand name medication must be used. And with the recent recalls of over-the-counter brand name medications such as Tylenol, generics have become the more easily accesible option for many patients. They are less expensive and work just as well as the brand name products.

So patients on Actos, rejoice because there is now a cheaper alternative! If you haven't been switched to the generic yet, talk to your pharmacist about when it might be available to you. Some insurance companies take about a month to six months to officially "recognize" the generic and add it to their plan, so it might take a bit of patience. But soon, you will be saving money and living a better life!

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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.

Metformin

As I was considering which diabetes drug to feature in my first 'drug post,' there was only one clear choice. The most prescribed medication for diabetes, and one that literally hundreds of my patients use is...metformin! Metformin is the generic name. Some of the brand names you may be familiar with are Glucophage, Glucophage XR, Fortamet, and Riomet (the liquid form of metformin).

Just a heads-up, remember that I am a pharmacist. So, when describing a drug, I will sound like, you guessed it, a pharmacist. Blame my training. I'll try to make things simple and easy to follow and understand, but if I've ever gone too "scientific" and you'd like things explained another way, or you have questions, feel free to let me know. My email will be available at the end of my post. An important thing to remember before I start: glucose is just a fancy name for sugar. I'll probably use glucose because it is most common for me, so just don't be confused by my terminology - I am referring to sugars. So without further ado...metformin!

How does it lower blood sugar: Something for you to remember: as a diabetic you have sugar (glucose) in your blood - kind of floating around your cells because for some reason it's not getting into them. Sugar in the blood and not in the cell is a bad thing. Normally insulin in your body helps sugar enter your cells, but in diabetics it just isn't doing the trick. Metformin makes your cells more sensitive to allowing sugar to enter - kind of like opening the door for sugar. More sugar in cells means less floating around in your blood, which means lower A1c, which makes for a healthier person.

Is that enough? Ok, so now sugar is going into your cells where it belongs, so we have a perfectly wonderful drug for diabetes and can be happy with that. Do you think that the scientists that made metformin thought that? You guessed it, of course they didn't! They wanted more "bang for their buck," so they thought of another way to keep sugars out of your blood. How did they do that? By not allowing it into your blood in the first place. Metformin is very special - it acts as a sort of bodyguard after you eat a meal. Metformin helps to keep some of the sugars that you eat from entering your bloodstream. If the sugars stay in your stomach and intestines and don't enter your blood, the result is lower blood sugar readings. Pretty simple, huh?

But wait, there's more! Would you believe it - your body actually produces it's own sugar! You see, our bodies need a certain amount of sugar for energy. Your brain lives off of it, as do many other important organs. So your liver has the important job of making sugar when needed. Unfortunately in diabetics, it will do this sometimes even when you have enough already in your blood. So for that reason, the makers of metformin decided to develop their drug so that it would stop the liver from producing that extra sugar.

Look at that - three different ways that metformin helps with diabetes! No wonder it is the drug that is chosen first for most new type 2 diabetics.

The effect on your numbers: So where does that put us? How does this change the numbers you are seeing on your blood tests? With metformin, you can expect to see a decrease in your A1c of at least 1-2% (example: your A1c could decrease from 10 down to 8 or 9 after metformin is started). Remember that A1c tells the story of your average blood sugars over the past 3 months. You could look at the blood sugar readings that you take during the day as photographs, whereas your A1c would be the title of the photo album.

An added bonus of metformin is that it might help to lower your bad cholesterol and increase your good cholesterol. There is a potential for modest weight loss when on metformin, but the average is only about 2.6 pounds, so it is not a "miracle" weight loss drug. However, it is unique because it is a diabetes medication that is weight neutral, meaning it does not cause weight gain. As you will learn later, this is not the case with all diabetes medications.

Dosing: Initially, most patients are started at doses of 500 mg once or twice daily of the immediate release (IR) form of metformin. Immediate release just means that the medication enters your blood all at once, versus slowly releasing all day long (extended release). If a patient is new to metformin and is starting at a dose of 500 mg twice daily, I usually recommend starting at 500 mg once daily for the first three days in order to decrease stomach upset. There is a less commonly used 850 mg dose of metformin that is available, which is started at one tablet daily with breakfast.

For some patients, extended release (ER) metformin is chosen. Metformin ER enters the blood more slowly, which leads to less stomach upset and discomfort. Since metformin ER only needs to be taken once daily, it is a good choice for patients that have trouble with taking a medicine twice daily (can't remember, varied schedules, etc). Patients are generally started on 500 - 1000 mg of metformin ER, taken with the evening meal. Do not cut, crush, or chew metformin ER because it is specifically made to disperse throughout the day, not all at once.

Because of unpleasant stomach upset and side effects, metformin should always be taken with food or immediately following the meal. We start metformin at low doses because of the high potential for side effects. Doses are then increased weekly if needed. Generally we do not see a response with metformin at doses less than 1500 mg per day, so don't be discouraged if your doctor keeps increasing your dosage. It may take up to eight weeks of being on metformin before full effectiveness can be seen, so patience really is a virtue.

Side effects: I have already previewed the major side effect of metformin, which is stomach upset. This includes diarrhea, nausea/vomiting, and gas. As I mentioned, taking the medication with meals and increasing doses slowly over days and weeks can help to minimize this. When starting metformin, patients sometimes complain of an unpleasant or metallic taste. This tends to go away within the first few weeks. More rarely we see skin rashes, itching, and sun sensitivity (sunburning easily) with metformin use.

A very rare (2-10 patients per 100,000 patients on metformin per year) but serious side effect that is caused by metformin is something known as lactic acidosis. Lactic acid is a part of our metabolism that helps us produce energy when we do things like exercising. At high levels, it can be very dangerous. Lactic acidosis can be deadly in up to 50% of cases. If lactic acid levels are too high, dialysis is required to remove the metformin from the body and to correct the increased lactic acid levels. Fortunately physicians and pharmacists are well aware of this side effect, and it is easily preventable if certain patients that are more at risk are not given metformin. Side effects from metformin are very rare and can be easily dealt with and prevented by taking the medicine with food and switching to a different medication if needed.

Last week I had a patient that was switched from metformin to glipizide. While her A1c was okay, her kidneys were not doing very well, which could lead to lactic acidosis. So, her doctor changed her to another medication. This leads me into a discussion of which patients would not be eligible to take metformin.

Who should not take metformin: Patients with kidney disease or kidney failure are more at risk of developing lactic acidosis, since metformin is removed from the body solely by the kidneys (if your kidneys are not good, metformin stays in your body too long, causing problems). Your doctor will do blood tests to determine the health of your kidneys prior to starting you on metformin. If your kidneys are not healthy enough, another medication will be used. As we get older, our kidneys generally do not work as well, so metformin is not recommended in anyone over the age of 80 years old, unless your doctor determines that your kidneys are healthy.

The liver is responsible for regulating lactic acid levels in our bodies, so anyone with liver disease should avoid metformin. Since alcohol has a negative effect on the liver, patients should be advised not to drink in excess (binge drinking, or chronic use of more than two drinks per day or at one sitting). I'm sure that the other effects of alcohol on diabetes will be covered in a future blog post.

Drug interactions: Certain stomach medications used for acid reflux (cimetidine - generic for Tagamet, and ranitidine - generic for Zantac) interact with metformin. Two antibiotics (cephalexin - generic for Keflex, and Bactrim) may increase metformin concentrations. You would think that this is a good thing, but it can lead to more harm than good (increased side effects, stomach discomfort and pain). The fluoroquinolone antibiotics (Levaquin, Cipro) may cause increases or decreases in blood glucose levels, which are also not good things for diabetic patients. There are other medications that I have not included on this list, for sake of space, so please remember to check with your pharmacist or physician, and make sure they are aware of all medications you are taking.

I know this is lot of 'pharmese' so far, but I am a pharmacist so what do you expect? Bottom line is that you need to always let your doctor and pharmacist know what drugs you are taking so any negative interactions can be avoided. Don't forget to ask your pharmacist to check for interactions before you stop to pick up a product from the cough/cold or vitamin section of the pharmacy, because these are also medications and they can interact with other things you are taking. Your doctor and pharmacist should be informed about all prescription and over-the-counter medications that you are using, as well as any allergies you have to medications.

Some folks have more than one doctor - always let all doctors know every medication you are on. And, use only one pharmacy so they can check for interactions. You run risks if you use more than one pharmacy - nobody knows all of the drugs you are taking, so you don't have a safeguard in place. So to sum up: make sure all doctors know about all of your medications, and use one pharmacy. Okay? It's best for you that
way. I'll step off my soapbox now.

Monitoring: Sometimes I have patients ask me why they have to make another appointment with their doctor before they will be given any refills. "I'm a diabetic, and I will be for the rest of my life. Why do they need to see me every year? Aren't they just going to keep me on my meds?"

This is a very valid question. As you can see from what I've been talking about in this post, there are many reasons why metformin (or any other medication) might not be appropriate for a patient. And, our bodies are always changing - what might have been the right medication and dosage for you when you started it might not be appropriate six months or even ten years later. Your kidneys and liver might not be working as well to clear the medication. Your control on diabetes might have improved or, sadly enough, gotten worse.

So at least once yearly, your physician will want you to come in for simple blood testing. This will include a serum creatinine (something that gives us an idea of how well your kidneys are functioning), fasting plasma glucose and A1c (remember the photos and photo album?), and other blood components.

The ADA recommends A1c tests twice a year and a full panel of blood tests once a year. Your doctor should be following that as a minimum. In the early stages of treatment, your doctor might test more often to track progress. And, really, how long does a blood test take? Most labs now allow you to make an appointment online so it's faster and more convenient for you. Sometimes you don't even need to see the doctor - you get lab work and they send in the prescription once they have the results. It's as simple as that. But remember, if they do need to see you, please make the appointment. They really are only trying to make sure they have the right medication and dose for you, and that your diabetes is being taken care of properly. We all want you to live a long and happy and enjoyable life.

Place in therapy for diabetes: Metformin is known as the cornerstone for treatment of type 2 diabetes. The current guidelines that we follow when treating new diabetics state that metformin should be started before any other medication, unless the patient is not able to take it for the few reasons I stated earlier. Metformin is also the only medication that is currently approved for use in pre-diabetics to prevent full-blown diabetes. It is also the only oral diabetes medication approved for use in kids (age 10 and up). Since insulin is the only other diabetes medication that can be used in kids right now (and let's face it, what kid wants to get a shot?!), it is a very popular medication for those very young diabetics. Unfortunately it does not work for type 1 diabetes, which is generally diagnosed in younger people.

If you would like to read more about metformin, here is another good website: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000974/

So there you have it, a review of our most popular diabetes medication, metformin. Next week I will move on to one of the different categories of meds that we use to treat high blood sugars, so you will want to stay tuned.

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.

Please feel free to email me at drk@solutionsfort2diabetes.com if you have any questions on metformin, diabetes medications, or other pharmacy issues.  I will attempt to answer all inquiries in a timely manner.  Also, if you have a suggestion as to other things you'd like to see me post about, or general pharmacy questions that you think other patients might have, please let me know.  Thanks for reading!

Welcome Dr. K!

When I started this blog, the title Solutions for Type 2 Diabetes seemed to be a bit grandiose.  I knew I wanted to offer practices that I had found to be effective, and share some of my frustrations.  My hope was that I would inspire you to fight the battle against the disease. Now, this blog can offer more to help you fight and win the battle.

I am very pleased to announce that a pharmacist will start writing for you and posting here.  Dr. Katherine King, licensed pharmacist who manages the pharmacy department in a large retail location, will start posting every Sunday.  Her first entries will have to do with the drugs used to fight diabetes - very likely she will review the drug you are using sooner or later.

Dr. K is one smart person who cares about her patients and wants to serve them.  You have become a virtual patient of her's and she takes your success in fighting diabetes very seriously.  In the very near future there will be an address to which you can email your specific questions to her.  Just be aware that she might not be able to get to every question - she does have a pharmacy to run, but she will answer them as she is able within the blog.

I look forward to learning from Dr. K, too.

By the way, Dr. K's posts will be based on her education and experience and will reflect her opinion based on that.  Since she cannot know your personal situation, you should always consult with your physician and pharmacist on treatment matters.

And, as always, thank you for reading.