1. Hyperglycemia Management – Medication Therapy
Janice Frueh, PharmD, BCPS
Associate Clinical Professor
SIUE School of Pharmacy
June 2nd , 2015

2. Objectives
Compare and contrast differences in the physiologic effects for glucose control of newer anti-hyperglycemia medications
Describe important considerations for effective and safe use of newer anti-hyperglycemia medications and medication delivery devices

3. Diabetes Self-Management Education and Support=
The City of New York. Accessed on May 2015

4. Oral & non-insulin injectable medications
Class
Agent(s)
Available as
-Glucosidase inhibitors
Acarbose
Miglitol
Precose or generic
Glyset
Amylin analogue
Pramlintide
Symlin
Biguanide
Metformin
Glucophage or generic
Bile acid sequestrant
Colesevelam
WelChol
DPP-4 inhibitors
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Nesina
Tradjenta
Onglyza
Januvia
Dopamine-2 agonist
Bromocriptine
Cycloset
Glinides
Nateglinide
Repaglinide
Starlix or generic
Prandin
Class
Agent(s)
Available as
GLP-1 receptor agonists
Albiglutide
Dulaglutide
Exenatide
Exenatide XR
Liraglutide
Tanzeum
Trulicity
Byetta
Bydureon
Victoza
SGLT2 inhibitors
Canagliflozin
Dapagliflozin
Empagliflozin
Invokana
Farxiga
Jardiance
Sulfonylureas
Glimepiride
Glipizide
Glyburide
Amaryl or generic
Glucotrol or generic
Diaeta, Glynase, Micronase, or generic
Thiazolidinediones
Pioglitazone
Rosiglitazone
Actos or genetic
Avandia
DPP-4 = dipeptidyl peptidase; GLP-1 = glucagon-like peptide; SGLT2 = sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:

5. Insulin medications and delivery devices
V-Go® Insulin Delivery System
Agent
Available as
Basal
NPH
Glargine U-100
Glargine U-300
Detemir
Lantus (Pen = SoloSTAR)
Levemir (Pen=FlexTouch)
Basal-Prandial
Regular U-500
Prandial
Regular
Humulin R
Novlooin R
Aspart
Glulisine
Lispro
Novolog (Pen=FlexPen)
Apidra (Pen = SoloSTAR)
Humalog (Pen=KwikPen)
Afrezza ® Inhaled Insulin
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:
Picture from Valertiras. Accessed on March 2015
Picture from Sanofi-Aventis. Accessed on May 2015

6. Antihyperglycemic therapy in type 2 diabetes: general recommendations.
Silvio E. Inzucchi et al. Type 2 DM Antihyperglycemic Therapy: General Recommendations Diabetes Care 2015;38:

7. At 3 month f/u = 6 choices for medication management
Antihyperglycemic therapy in type 2 diabetes: general recommendations.
At 3 month f/u = 6 choices for medication management
Silvio E. Inzucchi et al. Type 2 DM Antihyperglycemic Therapy: General Recommendations Diabetes Care 2015;38:
Silvio E. Inzucchi et al. Dia Care 2015;38:
©2015 by American Diabetes Association

8. At 3 month f/u =LOTS of choices for medication management
Antihyperglycemic therapy in type 2 diabetes: general recommendations.
At 3 month f/u =LOTS of choices
for medication management
Silvio E. Inzucchi et al. Type 2 DM Antihyperglycemic Therapy: General Recommendations Diabetes Care 2015;38:

9. PATIENT TAKE HOME MESSAGE: Individualized Approach to Blood Sugar Control Targets
Medication management of hyperglycemia focuses on:
Efficacy (how much the A1c decreases)
Hypoglycemia risk (patient AND medication risk factors)
Impact on weight
Other side effects
Cost
Silvio E. Inzucchi et al. Type 2 DM Antihyperglycemic Therapy: General Recommendations Diabetes Care 2015;38:

10. Non-insulin dependent
Produce
Glucose
Kidney
Liver
Normal Glucose Levels
Eliminate
Glucose
Non-insulin dependent
Brain
Neurons
Insulin dependent
Liver
Muscle
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; Accessed Online: May 2015.

11. Hyperglycemia Pathophysiology: Type 2 DM
Impairments in Glucose Regulation
Medications Impacting Glucose Regulation
Impaired insulin secretion
Deficient insulin release
Decrease in beta-cell mass +/- function
Sulfonylureas
Insulin resistance
Muscle cells have impaired intracellular regulation
Liver cells are less responsive to insulin and inadequately suppress glucagon levels
Metformin
Thiazolidinediones
Blunted incretin effect
GLP-1 receptor agonists
DPP-4 inhibitors
DPP-4 = dipeptidyl peptidase; GLP-1 = glucagon-like peptide;
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; Accessed Online: May 2015.

12. Oral & non-insulin injectable medications
Class
Agent(s)
Available as
-Glucosidase inhibitors
Acarbose
Miglitol
Precose or generic
Glyset
Amylin analogue
Pramlintide
Symlin
Biguanide
Metformin
Glucophage or generic
Bile acid sequestrant
Colesevelam
WelChol
DPP-4 inhibitors
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Nesina
Tradjenta
Onglyza
Januvia
Dopamine-2 agonist
Bromocriptine
Cycloset
Glinides
Nateglinide
Repaglinide
Starlix or generic
Prandin
Class
Agent(s)
Available as
GLP-1 receptor agonists
Albiglutide
Dulaglutide
Exenatide
Exenatide XR
Liraglutide
Tanzeum
Trulicity
Byetta
Bydureon
Victoza
SGLT2 inhibitors
Canagliflozin
Dapagliflozin
Empagliflozin
Invokana
Farxiga
Jardiance
Sulfonylureas
Glimepiride
Glipizide
Glyburide
Amaryl or generic
Glucotrol or generic
Diaeta, Glynase, Micronase, or generic
Thiazolidinediones
Pioglitazone
Rosiglitazone
Actos or genetic
Avandia
DPP-4 = dipeptidyl peptidase; GLP-1 = glucagon-like peptide; SGLT2 = sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:

13. GLP-1 Agonists

14. Take Home Points: GLP-1 receptor agonists
Efficacy: ~1% A1c reduction
Impact post-prandial glucose
4 -10 weeks for maximum glucose lowering effects
Impact on weight: Neutral or Loss
Other Side Effects/Concerns:
Thyroid carcinoma 
Acute pancreatitis
Gastroparesis
Narrow therapeutic index medications
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; Accessed Online: May 2015.

15. Take Home Points: GLP-1 receptor agonists
Short-acting dosage formulations
Exenatide: Take with a meal. Skip dose if usual meal missed
Long-acting dosage formulations
Common side effect: palpable nodule, erythema at injection site.
No dependence on meals
If dose is missed, take within 3 days of usual administration day . HAVE 2 ROUTINE ADHERENCE METHODS.
Exenatide, Albiglutide: May need up to minutes to prepare and administer dose. Keep instructions with medication not in use or in a safe location.
Only use needles provided.
Discontinue use 1 month before planning pregnancy.

16. DPP-4 Inhibitors

17. Take Home Points: DPP-4 inhibitors
Efficacy: 0.7-1% A1c reduction
Impact post-prandial glucose
4 weeks for maximum glucose lowering effects
Impact on weight: Neutral
Other Side Effects/Concerns:
Acute pancreatitis
Liver failure [alogliptin only]
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; Accessed Online: May 2015.

18. SGLT2 Inhibitors

19. Take Home Points: SGLT2 Inhibitors
Efficacy: 0.7-1% A1c reduction
Impacts fasting glucose
Impact on weight: Loss/Neutral
Other Side Effects/Concerns:
GFR < 30min/ml, ESRD , Dialysis [Contraindicated]
GU infection
Ketoacidosis
Triplitt CL, Repas T, and Alvarez C. Diabetes. In:Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy, 9th ed. New York: McGraw-Hill; Accessed Online: May 2015.

20. Insulin medications and delivery devices
V-Go® Insulin Delivery System
Agent
Available as
Basal
NPH
Glargine U-100
Glargine U-300
Detemir
Lantus (Pen = Solostar)
Levemir (Pen=FlexTouch)
Basal-Prandial
Regular U-500
????
Prandial
Regular
Humulin R
Novlooin R (??)
Aspart
Glulisine
Lispro
Novolog (Pen=???
Apidra (Pen=??)
Humalog (Pen=??)
Afrezza ® Inhaled Insulin
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:
Picture from Valertiras. Accessed on March 2015
Picture from Sanofi-Aventis. Accessed on May 2015

21. Picture from Valertiras. http://www. go-vgo. com/why-v-go
Picture from Valertiras. Accessed on May 2015

22. V-Go® Insulin Delivery System
Simple, discrete way to administer insulin
Do not have to travel with needles, pens, or vials
Maintenance Dose: Reach 50/50 split on daily basal-bolus insulin dose
V-GO Start Guide. Accessed on May 2015

23. V-Go® Insulin Delivery System
V-GO Start Guide. Accessed on May 2015

24. Afrezza ® Inhaled Insulin
Indication
Age > 18 years old
Type 1 or 2 DM
Contraindications
Chronic lung disease (asthma, COPD)
Precautions
(history of/at risk for)
Lung cancer
Diabetic ketoacidosis
Hypokalemia

25. Afrezza ® Inhaled Insulin
Efficacy: similar to prandial insulin options
Impact post-prandial glucose
3-5 days for maximum glucose lowering effects
Impact on weight: Weight Gain
Other Side Effects/Concerns:
Cough (common)
Throat pain/irritation (common)
Hypoglycemia (similar to prandial insulin options)
Fluid retention

26. Questions??