Diabetes Meds Old and New

Sep 12, 2016

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Eric has a plan. There is an RC truck that he has seen on YouTube that he really wants. It costs $70. Eric has decided he should get an allowance. He figures he should earn $5 per week. He also likes math, so he told me he'd have to work for 14 weeks to get his RC truck. He hasn't actually told Doris and I what he is willing to do extra that is worth $5 per week. But he is sure about the timing of his future chores…later. He can't start them today. His 11 year old schedule can't fit in any extra chores at the moment. "I can't start doing extra chores today Dad. I can't start before Monday."

It's September, and maybe instead of wanting a new RC truck, maybe you want to hit a new goal for your blood sugar control. Are you willing to change your diet or exercise routine? Do you want to try a new medication? If you are looking at medication, a reasonable question is: "Are all new medications better than older medications or just more expensive?"

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 won't 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 person's 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 doesn't 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 aren't sure why empagliflozin reduces CV risk. Researchers are now debating if the flozins help or hurt the kidneys. The jury is out, but it might be that flozins stress the kidneys at the beginning, but in the long term they are protective. Are the flozins better than the older diabetes medications, or just more expensive? There is a chance they might be better, but probably too soon to call it.

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 person's 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 don't want a new RC truck like Eric. This fall, I really should try to eat better, though. I eat too much fast food. I have too many late night snacks in front of the TV. I drink too many barley based beverages. I should eat more vegetables, and drink more water. But not right now. I'm kinda busy. I'm thinking maybe….. Monday.

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.

Canadian Diabetes Association - www.diabetes.ca


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