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Clinician’s Corner: Drugs for the management of Type-2 Diabetes

There are eight different organ systems that can affect blood sugars.  Researchers have developed drugs that address all eight of these systems.  Your Thompson Pharmacist knows all of the drugs and their end effects on you.  Here are three less commonly used drugs for the management of Type-2 Diabetes

ALPHA GLUCOSIDASE INHIBITORS

Mechanism: decrease gut carbohydrate absorption and slows carbohydrate absorption, by inhibiting the enzymes which are needed to digest complex sugars..

Expected reduction: HgBA1C= (.5-.8%) Expect lowering of fasting plasma glucose 35-40 mg/dl.

Target population: elevated after meal blood sugar levels.

Acarbose (Precose®)- Available strengths 25,50 & 100mg

Miglitol (Glyset®)- Available strengths 25,50,100mg

DOSE: Both acarbose and miglitol: Increase dose gradually to decrease adverse effects.  Usual dose is 50mg-100mg three times daily with meals.

Side Effects: dose related side effects include flatulence (gas), diarrhea, and abdominal discomfort.

PATIENT INFORMATION- alpha glucosidase inhibitors

  • AVOID in inflammatory bowel disease.
  • Administer 4g chewable glucose tablets or 15g gel in patients who develop hypoglycemia. — Patients should carry these with them. Because these drugs block breakdown of candy, orange juice and other sugars, a person with a low blood sugar is at risk.  Let your Thompson Pharmacist help you select a measured dose of glucose.
  • If you skip a meal, then the drug should be skipped.

Other use: prevention of dumping syndrome in post bariatric surgery patients.  Dumping syndrome is the effect of rapid stomach emptying, leading to rapid glucose absorption, and it is particularly common among post-bariatric surgery patients.  Dumping syndrome occurs in up to 75% of patients after Roux-en-Y gastric bypass surgery.  By slowing up glucose absorption after a meal, there is a significant reduction in dumping syndrome.

BROMOCRIPTINE  (Cycloset®)    0.8mg

Mechanism: works in the brain to normalize  neurotransmitter activities that , that induce, potentiate and maintain the insulin resistant and glucose intolerant state”

Dose:  0.8mg daily, increased until therapeutic dose 1.6mg-4.8mg  (2-6 tabs/day)

Benefits: cardiovascular safety and low risk of hypoglycemia and weight gain.

only lowers A1C about 0.5%.

costs up to $900/month

CAUTION:   fainting as dose increases; also nausea, dizziness and drowsiness.

Avoid if nursing.

Because of unique release mechanism, you may NOT prescribe generic Parlodel (bromocriptine) for Type-2 diabetes.

COLESEVELAM (Welchol®)

Mechanism: first lipid drug approved for blood sugar control. Colesevelam is a bile acid sequestrant, like cholestyramine (Questran).  Bile acids play a role in cholesterol and glucose metabolism. Reducing bile acid absorption can improve both.

DOSE:

  • 6 huge pills daily (or 3 tablets twice daily).
  • Or one packet (3.75gm) packet once daily with a meal. Mix 1 cup of water, fruit juice, or diet soft drink. Stir well and drink.

USE: add to metformin, insulin or sulfonylureas.

Benefit: lowers HbA1c 0.5%, but may lower LDL 20%

CAUTION in patients with triglycerides over 300 mg/dL; Avoid if over 500 mg/dL.
May increase triglycerides especially when combined with insulin or sulfonylureas. Advise taking glyburide, oral contraceptives, levothyroxine, or narrow therapeutic index drugs at least 4 hours before colesevelam.

We’ve come a long way since the discovery of sulfonylureas in the 1950’s.  There have been a lot of new drugs with unique mechanisms that we have covered the past couple of months.   Today’s three drugs are seldom used. In spite of that your Thompson Pharmacist keeps up with all of the treatment options for Type-2 diabetes.  Go Ahead and Ask… at Thompson Pharmacy it’s all for YOU!