Diabetes Meds Old and New

Nov 10, 2015

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

You know what the answer is? More kids playing hockey. I was ranting to Pat at the pharmacy the other day, and a little bit tongue in cheek, I found the same answer to every problem. Want to fix childhood obesity? Get more kids in hockey. Want to reduce vandalism around Dauphin? Get more kids in hockey. Want fidgety boys to pay attention in school? Get more kids in hockey. Want girls to gain confidence and learn to play on a team? Get more kids in hockey. And on and on. Obviously, hockey doesn't cure every problem. But winters are long and dark and we all have the tendency to sit on the couch and watch Netflix too much. I was just whining about the problem instead of doing something to try to fix it. But then came the Dauphin Breakfast Club.

In the pharmacy, we are often bombarded with new ideas to fix old problems. Sometimes you have to ask, Are all new medications better than older medications or just more expensive? Let's look at diabetes.

There are a new group of diabetes medications called the flozins. They have names like Invokana or canagliflozin, Forxiga or dapagliflozin, and the newest one Jardiance or empagliflozin. These flozins are called an SGLT2 inhibitors. They inhibit a sodium-glucose co-transporter in the kidneys. This means the kidney wont reabsorb as much glucose out of the urine, and you will essentially be peeing out excess sugar.

When used by themselves, the flozins have a low chance of making the blood sugar go too low. They have some unusual effects as well. The flozins may make the blood pressure go down a little and may make a persons weight go down a little. On the downside, the flozins put more sugar in the urine, and microbes love sugar. So flozins will make urinary tract infections and yeast infections happen more often. Because the flozins make you urinate more, the patient will be at increased risk of dehydration. This can be a problem, especially in older people.

There is more interesting news about the newest flozin, Jardiance or empagliflozin. Patients with type 2 diabetes and cardiovascular disease who are given empagliflozin seem to die less often. More specifically they seem to have less sudden cardiac death and less worsening of heart failure. Empagliflozin doesnt reduce the number of heart attacks or strokes. This is surprising since until now the only medication for type 2 diabetics that reduced cardiovascular deaths was metformin. And the researchers arent sure why empagliflozin reduces CV risk. So are the flozins better than the older diabetes medications, or just more expensive? There is a chance they might be better.

Let's have a look at insulins in type 2 diabetes. In type 2 diabetics, the newer more expensive insulin might not be any better than the older cheaper insulins. For years and years we have had Regular insulin and NPH insulin. Regular insulin is clear and works fast. NPH is cloudy and lasts a long time. In the last few years the drug companies have come out with insulin analogs. There are really fast acting analogs like Humalog or lispro insulin which are faster acting than Regular insulin. And there are really long lasting analogs like Lantus or glargine insulin that last even longer than NPH insulin.

Even though the analogs work faster and longer than the traditional insulins, the question is In type 2 diabetics, does that really matter? This is especially important as the insulin analogs are more expensive than the traditional insulins. When you look at blood sugar control in diabetics, you look at the blood test called a Hemoglobin A1C. It is a three month average of a persons blood sugar. There have not been significant differences in Hemoglobin A1C between type 2 diabetics on traditional insulin and those on the analogs. A scary thing for any diabetic is when their blood sugar goes too low. They feel nauseous, dizzy, unwell and in severe cases they can even lose consciousness. We call these states of low blood sugar hypoglycemia. Cases of severe hypoglycemia are no more likely in type 2 diabetics with the older, traditional insulin than with the newer analogs. There is one exception. Hypoglycemia over night while you sleep is slightly more common with NPH insulin than with the long acting analogs like Lantus. However, if the type 2 diabetic patient wants to use the NPH because it is less expensive, often if they take a healthy bedtime snack, the chance of overnight hypoglycemia while they sleep will be reduced.

One advantage of the analog insulins that has been promoted is that they are more convenient, and that is true in type 1 diabetics. But in type 2 diabetics, who are on oral medications for their diabetes, often NPH insulin can be given just once a day at bedtime, like the analog basal insulins such as Lantus even though NPH is shorter acting. And in type 2 diabetics, Regular insulin can be given just before a meal just like the faster acting analogs like Humalog. In type 1 diabetics, we say they should take their Regular insulin 20-30 minutes before their meal. However, in type 2 diabetics on oral medications, there is no proof that taking Regular insulin 20-30 minutes before a meal reduces the chance of hypoglycemia or improves Hemoglobin A1C. So are the newer, more expensive insulin analogs better than traditional insulin in type 2 diabetics. Probably not. If a patient or doctor really likes how the analogs work, they are a great choice in type 2 diabetes. But if cost is a real issue, the cheaper traditional insulins will work just as well as the analogs in a type 2 diabetic.

I think getting kids in hockey really does solve a lot of problems. The Dauphin Breakfast Club is a free drop in hockey program for kids born 2003 to 2009. Ryan Gardener, Devin Shtykalo and others got the support of local businesses and organizations, like the Dauphin Clinic Pharmacy, to pay for the ice time. It runs 7:15 to 8:15 am Mondays and Thursdays. See the Dauphin Rec Commission website for more information. Eric has been a couple of times and really enjoys it. So good on the organizers of the Dauphin Breakfast Club. They are solving the world's problems one kid in hockey at a time.

We now have this and most other articles published in the Parkland Shopper on our Website. Please visit us at www.dcp.ca

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

Dauphin Breakfast Club - http://dauphinrec.com/index.php/news/559-dauphin-breakfast-club
Canadian Diabetes Association www.diabetes.ca


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