Diabetes Medications and Types Of Insulin



hi everybody welcome to the webinar we're just going to get started now so today we have Elaine cook to share with us and so just before we start I'm going to let you know that's on the bottom right hand corner we have the chat box for everybody I don't regulate that or I don't um facilitate the conversation from there feel free to chat with one another if you do have a question you can type it into the bottom left-hand corner and the Q&A pod and we will address those questions at the end so without further ado we'll get started we are generously supported by Janssen and onetouch and so I'm gonna give it over to Lynn Cook who is a pharmacist and the CDA so sorry CDE she's a certified diabetes educator and today she'll talk to us about diabetes medication so Elaine please take it away hello everyone just before I do it I just going to mention to Sharon that someone can't see the visual apparently so in the chat box there so today yes our topic is diabetes medications and what we're going to do is just talk a little bit about very little bit of difference between type 1 and type 2 diabetes and what causes the high blood sugar when you have type 2 diabetes and then we're going to go through the medications talk about the oral medications injectable and insulin and just a little bit about hypoglycemia so I'm just looking at my little screen here so as all you probably know if you have type 1 diabetes the body has destroyed the cells that make it make it able to produce insulin and that type one has to be treated with insulin in type 2 diabetes it can be either a lack of insulin or a lack of the action of insulin that's called insulin resistance and of course you all know I hope that type 2 diabetes is a progressive disease by the time you get diagnosed with type 2 diabetes the ability of yours beta cells in your pancreas to produce insulin is already only at 50% and that loss continues so realistically eventually almost all people with type 2 diabetes will require insulin even if it's just one shot a day to control their blood sugar and there's a lot of fear about insulin but I think you all just need to think of it if it's just another choice of therapies so I have this little graphic in it sorry I forgot where I was and you know to treat your diabetes you have to control your lifestyle so you have to look at your portion control the types of foods you're eating looking at your weight getting regular physical activity and stress is very important so you need to find ways to deal with stress as well and of course I'm a pharmacist so when you're prescribed and medication it's really important that you take it and if you're not taking it it's really important to let your doctor know that you're not taking it so he doesn't think well they're on that and that's not working so I'm gonna try something different so where does the high blood sugar of type-2 diabetes comes from a lot of times the very first thing that changes is that the liver starts to release more and more glucose because glycogen which is from where the glucose comes is stored in the liver and that increases your blood sugar and primarily it's your fasting blood sugar which is your morning blood sugar that starts to increase at that time and then the pancreas it eventually will get so there's decreased amounts of insulin secreted and when you have less insulin the insulin takes the sugar out of your blood and puts it in your muscles so if you have less insulin more sugar stays in your blood and again it can increase your blood sugar and there is another hormone that's released in your pancreas by different cells and it's called glucagon and glucagon actually lets your body release more sugar into your bloodstream and even though you lose the insulin you do not lose the glucagon so the glucagon adds more and more sugar into your bloodstream and we have this insulin resistance so the the insulin would take sugar into your muscles and your fat cells energy and four stories but because the insulin can't work it's like coming up against a brick wall more sugar stays in the blood increasing your blood sugar the amount of carbohydrates you eat often increases because of this hormone glp-1 which is a naturally occurring hormone that all of us have that helps regulate your appetite it helps regulate the insulin secretion and help to regulate the amount of glucagon that's released as well so all of those things combined one or the other or gradually maybe more than one of them cause that increase in blood sugar and the reason I've done this it's because I wanted you to know where do medications work often people tell me oh I have to take another medication so I've been bad no it's physiological changes that I've just explained and medications work in different areas so times times you have to use multiple medications to get your blood sugar under control so the drug called metformin and also insulin and the other two that are down there they work by decreasing the amount of sugar that it's a lot of dietitians call it leaky liver so the amount of sugar that's leaking out of your liver and that's primarily where metformin works and then we have that causes lower blood sugar and then we have medications that help your pancreas release more insulin and those are the things that are glyburide glipizide gonna provide and I'm going to talk about these in a little bit while a little while as well there are pagan I'd the insulin the glp-1 drugs that are injectable and the dpp-4 inhibitors so don't worry about the names because they're gonna come up in a little while but what happened then is it increases the amount of insulin and it suppresses the glucagon in different drugs which we'll get into later so that works to lower your blood sugar right and then we have drugs that are called thiazolidinediones great big word Rosie go to zone Avandia pico de zona act they're primarily action is to decrease that insulin resistance and let the insulin take the sugar into your fat and muscle cells insulin does that as well and metformin to a very small degree does that and then we're going to have medications oh by the way it lowers your blood sugar so then we have medications that work in the intestinal system in your gut so we have a acarbose which slows the absorption and we have drugs that affect that hormone I talked about the glp-1 whether it be a glp-1 added on or a dpp-4 and of course what happens then is it's going to help to lower your blood sugar so hopefully that kind of overview just gives you an idea of why you need multiple types of medication and please note that insulin tends to do all of those things so metformin so metformin its primary action is in the liver as I said it slows that release of the sugar from the liver and secondary effect to a minor degree it decreases insulin resistance and it's taken with food any of you that have already taken that form and know that it can cause some side effects so if you take it with a small dose and gradually increase the dose those side effects are diminished and the maximum amount of that is 25 to 50 500 milligrams per day but about 1,500 milligrams so three tablets a day of the standard tablet is about 75% of the action of metformin so as possible side effects the nausea the vomiting the diarrhea those are probably the ones that if you're going to experience you're going to experience that one the most some people get headache a little bit of agitation sweating weight loss some people think it's because it makes you nauseous but there has been studies that show that it can cause a little bit of weight loss and if you take more than 1500 milligrams for more than five years there has been some evidence that it might decrease vitamin b12 levels but there's not enough information out there to tell you the supplement with b12 but you can do it it does not cause hypoglycemia this is a big misconception I've had a lot of people tell me oh well you know I take an extra metformin if I my blood sugar is really high well it's not going to drop your blood sugar from where it is it's going to prevent it from going higher by preventing that sugar coming in from the liver so metformin by itself does not cause you to have low blood sugars otherwise known as hypoglycemia or a blood sugar is less than four what it does and it takes about two weeks for it to work is it it has a biggest effect on what your morning blood sugar is that's that fasting blood sugar and it can decrease that from about 3.3 to 3.9 millimoles per liter and usually it's not right away it tends to take about two weeks for those effects to be noticed and a lot of oral medications lower your a1c in this one percent range so a1 see the tests that you go for every three months which is a percent number that reflects what your average blood sugar has been for the previous three months in the case of metformin it will lower your a1c approximately one to one-and-a-half percent and then we have the thiazolidinediones I'm going to call them T's a DS these are the drugs that have had a lot of study and bad press and in Canada it's you'll have to have a contract with your doctor to start this medication to know that you've been made aware of any possible side effects and that's the rosy glitter zone known as Avandia or the PIA glitter zone known as Actos what it does is it decreases that insulin resistance so it lets insulin carry the sugar into the cells and one of the things they noticed about this medication is that it tended to keep that effect for a longer time than a lot of oral drugs and it's secondary effect is it effects that sugar release from the liver as well and again by itself it can make you have a low blood sugar because taking it does not drop your blood sugar down really quick doesn't matter if you take it with or without food one of the challenges this drug is it could take up to 12 weeks to work and when it was a popular medication a lot of people and it was expensive and it still is well I don't think well I've taken this thing for two weeks and not much has changed but unfortunately could take up to three months for it to have an effect the side effects of those that I've listed they're probably the most important that came to light is the fluid retention fluid retention is retaining fluid in the body which led to some heart failure which is one of the reasons in the studies that were done that there was a slight increase in the risk of heart attack but it was always not to be used in anybody who had heart failure and now it should not be using anyone that has any cardiovascular disease occasionally it could have caused an upper respiratory tract infection so that would be like nasal stuffiness etc there have been some signs of it causing a wrist fracture that's primarily been in women with long-term use but as I said this class of drugs nowadays are very rarely prescribed although in the States they're starting to use them again again it's effective primarily on that fasting that morning blood sugar and it decreased that by about 2.2 to 3.3 millimoles and it's again affected a1c from about one to one and a half percent so very similar to a lot of these oral drugs we have a class of drugs that they call sulfonylureas that affect the pancreas the beta cells so that's glyburide glucoside which some of you may know is dianne micron gloom it provide which isn't used a lot known as Amaral and what they do is I used to use an analogy like it's your if your pancreas is a sponge these drugs squeeze the sponge to get the insulin to release into your bloodstream so that it can work and these medications depending on the form because some of them come as regular tablets and some come as long acting tablets like glucoside comes as a diam micron mr whereas glyburide is usually once to twice a day daya micron regular tablets can be up to three times a day and die a micron mr even if you're taking three or four of them only needs to be taken once a day it's important when you're taking this medication that you have regular meals because this medication squeezes your pancreas to release that insulin the side effects hypoglycemia is quite common in these especially if you've missed a meal or you've done more exercise they do tend to cause a little bit of weight gain up to about 5 pounds if a person is allergic to sulfa not it's not always a problem but it's a concern sometimes the doctor will give a trial of this to see and the grab your egg one should not be used in anyone you have kidney failure the Glick aside which was the dye a micron that gonna provide their newer agents and they are more dependent on what your blood sugar is and I called it glucose dependent on these slides so whereas glyburide it's like the indiscriminate one of the bunch it will squeeze your pancreas and release insulin no matter what the glucoside and the cadet provide they pay attention to what your blood sugar is and they release insulin based on what your blood sugar is so they're less likely to cause that hypoglycemia over the glyburide and again they decreased your fasting blood sugar your morning blood sugar almost up to 4 millimoles per liter and decrease a1c one to one and a half percent there's another group that work very similar to those sulfon areas the Magritte knives they also work in the pancreas so repair go night which is known as glucan or m– the tinkle nide which is star licks these medications they're they work really quick so they have short-term and it is again depending on what your blood sugar is release of insulin and or it's none of these are going to work the so funny areas or this if you don't have a functioning beta cell people have been on glyburide or this type of medication for a very long period of time and their blood sugar is going up they probably don't have a lot of function left in their beta cells this almost lacks like an oral insulin we'll call it because it acts very rapidly when your take this medication you take it only with food and it works very quickly and it has its peak action within about an hour lasts for up to four it's usually taken at the mealtime or up to 50 minutes before your meal time and they usually can take up to one to four tablets because it really depends on the size of the meal and how well it's working to control your blood sugar two hours later this is a medication is often used for people that are really irregular eaters they don't eat at the same time of day whereas with the cellphone areas it's more important to have that regular eating this one because you don't take it if you don't eat right and it can cause hypoglycemia but much less so then that was so funny Oreo drugs and it can cause weight gain it reduces your after-meal blood sugar so your two hour after BL blood sugar by up to 3.3 millimoles per liter which is pretty big and it reduces a1c one percent for the glucan or more penguin ID and only a half a percent for them take or not that's all we don't really see that starlet's product used very much at all in Canada so then we have the glucose alpha-glucosidase inhibitors and it's called blue Colby or used to be called Brandy's it's called acarbose and what it does is it slows the rate of absorption if you slow down how fast it makes your blood sugar rise it's gonna let the insulin that you do have work a little better it's always taken with the first bite of the meal and the dose should be increased slowly so they take it with one meal and then they could take it at other meals or they might even increase the dose from fifty to a hundred milligrams and every two to eight weeks is when they increase the dose this drug has a really big problem with causing gas it's all abdominal things so you know abdominal discomfort the gas is something that's a real challenge for a lot of people someone told me it you have to really want to be alone for this medication and unfortunately taking an antacid or taking some stomach medication does not relieve that abdominal discomfort it by itself does not cause hypoglycemia but should you be on this medication with any medication that can it would be very important that you treated that hypoglycemia with dextrose tablets not with orange juice not with honey because those are carbohydrates right and it would slow the rate of absorption so if you had a low blood sugar when you're on this medication you have to use dextrose tablets such as decks 4 there is a straight decks tablet available it reduces your after-meal blood sugar almost 3 millimoles per liter and every decision anyone see from 1/2 to 1 percent then we had therapies that came out about five or six years ago that were called incretin therapies that have their action in the gut and we have a incretin hormone that i was saying was naturally produced in your intestines and it is released in response to eating and the main one there's a couple but the main one is called glp-1 or gluts gun-like peptide once and there's lots of different actions of glp-1 that helps your blood sugar be regulated and when you have type-2 diabetes you actually have less glp-1 than someone who doesn't have it and that's going to be important in a little while and the challenge with the glp-1 naturally occurring it is inactivated within about two to eight minutes in every one by an enzyme is called dpp-4 okay and that happens in every person so multiple actions of glp-1 naturally occurring to reduce your blood sugar or in fact to maintain your blood glucose if you don't have diabetes is again depending on what your blood sugar is it helps release of insulin help stimulate that release of insulin depending on what your blood sugar is it will suppress that glucagon glucagon would have come to your rescue and if you don't eat at all all day long glucagon will produce sugar because your body needs sugar to act right but as I mentioned at the beginning that gluts gone and type-2 is often like on a rampage so glp-1 helps suppress that action of glucagon it slows gastric emptying so it slows the rate of absorption of food and animals it has improved beta cell function and increase the beta cell mass it helps give a person a feeling of fullness to help them realize when it's time to stop eating which is when you lose some of your glp-1 a lot of people have type 2 ovary because they don't have that action to make them realize that they're full so of the incretin therapies dpp-4 inhibitors they're around to slow the action to slow the inactivation of glp-1 which I told you was inactivated by an enzyme called DPP for so these inhibit the action of that enzyme so they're acidic Lipton which is januvia saxagliptin which is onglyza linagliptin which is true gentleness can be used by themselves or they can be used along with metformin and in fact there is combination of all of those medications with a different name Jan you met combo glides and right this minute the other one just left my brain so I'll tell you that later side effects most people do not experience any side effects with this class of medications it is possible it can cause that stuffy nose but it doesn't have any effect on weight at all and most people don't notice when they're taking it it reduces the after meal blood sugar 2.7 millimoles per liter and its effect on a onesie is almost up to that 1% point 8 to 1% and then we have the these are injectable therapies glp-1 analogues so exempt ID which is known as by ADA it's injected twice a day 5 to 10 micrograms it's given with meals it's that's important and then there's liraglutide which is known as Victoza which is injected once a day in the morning this can be added on to metformin or on to someone who's taking metformin and a cell phone a urea as well and I have seen a lot of people who are on it just by themselves now because it tends to be looking at multiple effects that happen in the body that cause the type 2 diabetes the analogues are not broken down by the DPP for enzyme so it's not affected by that the side effects nausea more so with supply ADA after about 36% of people get nauseous with by ADA with the liraglutide they start off being nauseous but usually after about 2 to 3 weeks that nausea diminishes anybody who's taking by ADA or the Vic Toews and still feeling nauseous should just eat smaller more frequent meals as well as the nausea these medications can cause vomiting diarrhea it can cause hypoglycemia if it's used with a drug that does like the cell phone urea drugs by itself limited amount of hypoglycemia weight loss averages almost 2 kilograms but there have been people that report significant amounts of weight loss and maintain weight loss with these medications there have been stories of people losing 40 pounds or more but the studies that were done originally with this drug before it was released on average it was just at 1.9 kilogram which is just under 5 pounds it reduces your after meal blood sugar by two point seven to four point 5 millivolts per liter so that's the biggest one that we've talked about so far and a1c can be anywhere from half a percent to 1.3 percent and I have actually seen people that have had a two percent reduction in their a1c so then we have a new class of drugs that has come out actually it was released in Canada somewhere about February and those drugs work on the kidney so I thought you should know what happens normally in the kidney so the kidneys play a really important job in maintaining your blood sugar control because normally in the kidney it filters about a hundred and eighty grams of glucose every single day but because it wants to keep that it virtually reabsorbs all of that so you get to keep that into your circulation because we need glucose for our energy etc our main fuel so there are two sort of proteins that are in the kidneys and they're called sglt2 and s glp-1 the FD LT – it reabsorbs about 90% of glucose the other one about 10% so that essentially no glucose gets excreted now this isn't someone without diabetes when you have type 2 diabetes number one years ago we used to test for diabetes with urine tested cuz glucose was spilling over because it was exceeding the amount that the kidneys could work on but in type ii after a while your body actually reads or more and more glucose so again it adds to the blood sugar so this sglt2 stands for sodium-glucose cotransport or two and it's the inhibitors so inhibiting the the action of that is going to let your body release more sugar because that sglt2 helped reabsorb 90% of it right the one that we have in Canada is Canada frozen or invokana it's taken once a day before the first meal of the day and what it does is it helps you pee out about 300 calories glucose per day it increases the urine though it can be used alone or it could be used in combination with metformin it could be used in combination with a sulfonylurea drug and it can also be used in combination with insulin it's not used anybody whose renal function has decreased and your doctor would know this number so anyone who had a estimated GFR globular filtration rate of less than 45 these people would not use this medication so in the Kanaka flu then there's a number of side effects and I don't know why that disappeared sorry of course because you're helping Pete out more sugar you're going to pee more increase urination and it can also cause dehydration which can cause that dizziness that constipation and the thirst so with the dehydration you're at higher risk of getting dehydrated if you're over 65 if you take blood pressure medications and then specially diuretic drugs like hydrochlorothiazide or if you're on a low-sodium diet or again if you have kidney problems you're at greater risk of having that dehydration it has been known to cause urinary tract infections because it's making a lot of sugar in the urine as well as causing genital yeast infections they have found though that they're not ten they don't tend to be ongoing it basically you tend to get those infections at the start of the therapy but after a while it doesn't happen because it can keep more potassium in your body as well there can be an increase in the blood potassium so some of those kidney problems this would be a big problem for them there is an increased of low blood sugar if it's used with a drug that can cause low blood sugar so if you're taking in volcana and glyburide or dye a micron or gliclazide or the medical at night or the insulin there is an increased risk of this drug causing a low blood sugar but by itself it doesn't actually cause low blood sugars it lowers the a1c up to three percent this is a pretty large number in a pretty awesome result and I think we're going to see a lot more people on this medication and there are more of this medication coming by the way in the states they already have a couple of different ones so they I'm going to talk a little bit about insulin so someone who does not have diabetes then this light blue line represents the insulin that's released normally in a body the B is breakfast Ella's lunch D is dinner the HS is bedtime so your body has a pretty rapid amount of insulin release to cover a meal when you eat and then it tapers off and goes down so you're looking for an insulin if the insulin could mimic this normal insulin secretion bolus means meal time then a bolus insulin that match that would be a really good choice to look at and our body has a requirement for what they call basal or I'll call it background insulin that you have to have a little bit of insulin all the time for your body's functions for everything to work correctly so again if you could get an insulin that kind of mimics that basal amount that your body needs then that would be an ideal insulin so just as an example here this is the normal doesn't have diabetes that was just like I showed you and that keeps your blood sugar pretty much controlled this is an American slide that I've borrowed so that's why the numbers on the side are milligrams per deciliter and not millimoles per liter now somebody who has type 2 diabetes even if they're not on this is just there naturally what happens in the course of developing type 2 is it get a very blunted and delayed release of insulin this is again why your blood sugar can be so much higher because it's not controlling your blood sugar when you're mealtime glucose level goes up so see these are all the different types of insulin there currently available in Canada and you'll find many different charts especially on the internet that have slightly different numbers these numbers they come from the Canadian Diabetes Association's guidelines for the treatment and prevention of diabetes so there is insulin that act really quickly they're called rapid-acting insulin analogs so they're man-made insulins Humalog which is list Pro Noble rapid which is this part Piedra which is blue icing and they really work in within about 10 to 15 minutes and they are action one-hour peak usually you know one to one-and-a-half hours and they'll have some residual effect for up to three to five hours they have the short acting insulin which is known as regular or R or Toronto this is a human insulin in Canada we have human we don't have beef and pork anymore which I'm sure you all know but I've been around long enough that there was beef and pork inside it takes about 30 to 60 minutes for short-acting insulin to work that's why it's really important if you're taking anything that has is our regular insulin in it that you take it at least 30 minutes before a meal it can take two to three hours for its peak action to occur and it can last up to six and a half hours and there's an intermediate acting insulin which is known as n pH or n insulin it takes one to three hours to work and in some people up to four hours the peak action of that insulin is over five to eight and then has an action lasting up to 18 hours there are pre-mixed human insulin and these numbers resent represent how much our insulin and how much and influenced so 3070 in sperm would have 30 percent of regular and 70 percent of n and there's a forty sixty and a fifty fifty they start to work because they're a premix they're going to have the r action in that 30 to 45 minutes for the meal and their peak action is four to almost nine hours and the duration is 10 sixteen hours again this was if you're taking anything that has an R in it and you were taking it for your meal time you need to take it at least 30 minutes before a meal you have biphasic infirm which a lot of charts will cause call you a mixed analog insulin but in fact it's not a mix of anything it is just a portion of the rapid-acting insulin has had protamine added to it so it has a longer action so it has some immediate action and has some longer actions I'm gonna show you some graphs of these in a little bit so you Malad mix 25 so 25 percent of it is going to work right away 75 percent a little bit later it also comes in a mix 50 that's usually for a bigger eater so it has 50 percent of it working right away and 50 percent of it having a long action and we have long-acting insulin analogs a lot of people are familiar with the name Lantis which is glargine which takes about 90 minutes to work and it's basically a flatline insulin there is no peak it's really the closest to mimic that basal insulin I showed you a minute ago and it's action lasts around 24 hours in most people the other long-acting analog is dead Amir known as Lev Amir it takes about 90 minutes to work it does have a slight peak doesn't go up really high it has a little slight peak an expiration of action can be very dependent upon its dose and the person so they say 16 to 24 hours see a lot more people in this insulin on it twice a day but both lantus and large mean I have seen twice a day so this is a graphic example of how fast they were so bolus or mealtime insulin this would be the fast-acting the rapid acting that list Pro at spark blue scene Humalog no a rapid and a peed rest this would be the are insulin so it's just looking at the difference between these the fact that the our insulin takes longer to work and stays around longer it's not going to ideally control that post-meal blood sugar and because of its action longer it's probably going to cause more chance of a low blood sugar then we have the Basel influence which is that background insulin so we have the intermediate acting mph again it's action is 12 to 20 hours they may be slightly different numbers in the chart because again I've borrowed this slide from another presentation the long-acting insulin analogs such as the Dead Amir in this case it's saying it's action a 6 to 23 hours again depended on so and it does have that slight little peak there and then we have the large or Lantis insulin and it again takes about 90 minutes to start working but it's pretty much a flat line insulin and again probably mimics normal insulin secretion much better so when you're using insulin and type 2 diabetes when do they usually start it as again I said it's just another choice of therapy when person is taking oral medication or other injectable medication and their a1c is still elevated they can't get it can totally controlled usually an insulin is added and in type 2 diabetes often just at bedtime to start with so that's basal or background insulin once a day should be most people bedtime but it can be at mph would be like twice a day breakfast and supper and I have seen both Landis and and leva mirrored largely and dead Amer uses in the morning instead of at night often at so people will remember it more so it's once a day it's you don't take stop taking your other medications and quite often just that one insulin so that's going to get your background amount of insulin done look after controlling your blood sugar for a very long time and some people may never go past this insulin the idea with this insulin is to start with a low dose slowly titrate it up so it's like 10 units at bedtime and the person injects one extra unit every day until their morning shut blood sugar is less than seven or what ever target your doctor decides on so the long-acting the glargine dead in there they do mimic that natural insulin release much better and have a much lower risk of hypoglycemia whereas NPH can cause hypoglycemia a lot more frequently so this is just showing you the Green Line there is the mph when I drew this I couldn't get too big of a peak so it's it can cause low blood sugar between that especially at 4:00 a.m. period of time there if it's once a day at bedtime and then the purple here or the red is the Lance's the glory gene so pretty flat and then the dead Amir has just that slight little peak to it so just as a representation that white line would be how your blood sugars would be going up okay so often if you're been on that Lantis at bedtime and your morning blood sugar is great but your a1c is still high there is probably going to add a bolus or a mealtime insulin once a day right so usually it's a rapid acting because that's going to be mimicking the natural insulin better at breakfast or they'll say you can pick the meal it has the highest change in blood sugar from before to after but breakfast is quite frequently used because your your body naturally has a bigger increase of blood sugar in the morning and again quite often just those two times a day is enough to control a person's blood sugar for a very very long time the rapid-acting insulin it would be used 5 to 15 minutes before a meal Humalog novo rapid a Piedra or list pro as part and glue scene and you would check your fasting blood sugar and you would check your blood sugar 2 hours after a meal aiming to get to that 8 to 10 or your doctor might say well just check your fasting blood sugar before you take that insulin and before the next meal and to see where it's at at that time this is just an example of a long-acting insulin which would be I've used the glory nor the Dead Amir lines here with just adding one meal so the orange is representing the rapid-acting insulin human insulin which is the R and the n insulin it does not mimic normal insulin physiology so there have a much greater chance of the low blood sugar again our regular Toronto is that at least 30 minutes before a meal or if you're taking a 30 70 40 60 50 50 again you'll improve your blood sugar greatly if you're on that type of insulin and you take injected at least 30 minutes before a meal and NPH insulin is a cloudy insulin it's very important it's resuspended never shaken before you use it because though it NH has a great variability from day to day so just rock it and roll it back and forth ten times each don't ever shake it the premix is such as the human 3070 the Knovel in 30 70 that 30% are the 37% those are probably the most common ones you see this would be an example of using a combination the 30 70 insolence you can see that there's lots of spaces where there's blue underneath those lines and those make you much greater chance of having high low life low blood sugar and also not controlling the meal increase in blood sugar so there's also an analogue biphasic insulin which again closer to the normal insulin action needs to be mixed by that rocking and rolling ten times and because it has analog insulin in it it can just be injected 5 to 15 minutes before or even right after the meal this would be an example of it this one here is an oval mix 30 or like the Humalog mix 25 and sometimes this is sufficient although it looks like it's missing the lunchtime sometimes just taking a little bit at lunch if that's a big problem will be good for this insolence so then basal bolus therapy this is definitely done with analog insulin the long-acting lantus Leben Mir and the rapid acting insulins because you've got the background with the long-acting and then the rapid acting is going to look after those meals and that's what net happen naturally this isn't for everyone but this is certainly what a type 2 patient is often doing so this is just an example here's the background amount and then we add in rapid for breakfast rabbit for lunch and rabbit for dinner and you can see that's the closest to normal insulin release so for insulin therapy the side effects low blood sugar is the premium reason that people have a scare about insulin but it's something that can be managed so low blood sugar is less than 4 millimoles per liter and it's most often caused because people miss a meal or have more physical activity than planned or inject their insulin in a higher amount than they should so preventing it is knowing those action times that I've talked about following meal plans always having extra carbohydrate around for physical activity and always carry treatment for hypoglycemia with you at all time and if you're going to do exercise monitor before and during exercise or long driving and weight gain prevention it is a common side effect with insulin but healthy meal plans and exercise and talking to a dietitian can really help you with that so when you're using insulin almost all insulins lasts for 28 days at room temperature so when you're using it you want to use it at room temperature you do not want to put it back in the fridge it doesn't extend its time and cold insulin hurts let in their last 42 days anything that's cloudy again resuspended by the rocking and rolling ten times and never shake it always rotate your injection site you want to pick an area about the size of a postcard above the belly button to one side on to the other side below the belly button one side and the other and rotate those sites weekly so for one week you use a postcard size area for every injection then you rotate so you're not using that site for three more weeks to help the skin heal and always press on your tummy to see if you have any lumps or bumps and avoid those because that could be something called little hypertrophy always use a new needle dull needle and can cause more damage to the skin and little hypertrophy is overgrowth of the fat in your subcutaneous tissues and it does it changes the action of the insulin you don't ever need to have a needle length longer than six millimeters there's even syringes now that are six millimeters and ten needles six millimeters or less four is all you need stick it in straight in count ten seconds before you remove the needle from the skin and don't jab just put it there and put it in just to finish off quickly here just a little bit about hypoglycemia so mild to moderate hypoglycemia is defined as a blood sugar of 2.8 to 4 millimoles per liter it causes like dizziness confusion sweating weakness hunger trembling drowsiness and not everybody experiences the same side effects if the blood sugar is less than 2.8 that's considered a very severe hypoglycemia and it needs a different treatment so these are all the different symptoms that could happen in hypoglycemia but the symptoms vary from every single person stopped by your pharmacy and get a charts and gives you all of these the trembling palpitations sweating anxiety hunger nausea some tingling difficulties thinking or concentrating some confusion feeling weak or drowsy or blurry visions or having trouble speaking correctly or getting a headache but everything varies it's individualized dizziness always check your blood sugar if you're having these symptoms check to see if your blood sugar is less than 4 millimoles per liter if you've had really high blood sugar for a long time and you're starting to get your blood sugar lower you might experience some of these symptoms at higher than 4 you can treat it but just don't over treat it just take a little bit of treatment so treatment of hypoglycemia always test as I already mentioned some people get hypoglycemic symptoms higher when their blood Sugar's starting to go down because their body's not used to that so if it's 2.8 to 4 millimoles you want to treat with 15 grams of a fast-acting carbohydrates such as dextrose tablets there's one called x4 when your blood sugar is less than 4 you take 4 decks 4 and they have 4 grams of dextrose each you take 3/4 of a cup of juice or regular pop 2 3 teaspoons of sugar or honey or have 6 lifesavers test your blood sugar 15 minutes later retreat if your blood sugar still stays less than 4 and if your next meal is more than 60 minutes away you want to have 15 grams of carbohydrate and a protein such as a half a cheese sandwich or a slice a whole-grain bread with maybe a tablespoon of peanut butter if the blood sugar is less than 2.8 you need more to treat it you have to take 20 grams of a fast-acting carbohydrates such as 5 2 X 4 and 1 cup of pop regular popper juice 4 teaspoons of sugar or honey or 8 lifesavers again always retest in 15 minutes to see if your blood sugars come up and if necessary retreat it and if your meal is more than an hour away have 15 grams of carbohydrate in a protein if the person is unconscious and you would know if you're on insulin is only I usually occurs and type 1 individuals they would administer another injectable therapy called glucagon and that is that and if you have any questions I'd be happy to answer them thank you so much and Lee that was really really clear so thank you everybody for coming if you have questions please enter into the Q&A box on your bottom left-hand corner and I will facilitate it and ask it to Elaine as you are thinking about questions if you have two minutes to fill out the post survey you can just click on the link right there and again it will help us just to better our programs and I guess just as people are thinking about their questions I have one question so Elaine if somebody was to take home a message today what would that be I think it's really important to know what the medications are that you're taking how would they work and I think you need to know what your doctor has decided or your endocrinologist has decided is your target blood sugar in general people are to aim for four to seven before a meal and 5 to 10 two hours after but those can be individualized testing with your with the blood glucose test strips is really important for someone who's on a medication that might cause a little blood sugar or might cause no basically can cause a little blusher people who just take metformin or that you don't have to test a lot because it it doesn't tell you anything I always tell people if you're going to test test with a purpose test with some IV in mind but it is important if you have a medication to understand it and to take it thank you so just a couple of comments people are really enjoying the presentation and they would just want to thank you for the presentation so I do have a question here should someone speak of ice from an endocrinologist before going to insulin I'm type 2 and have been on metformin for 12 years usually your family physician can start you on it it's not necessary to go to an endocrinologist and in fact if your doctor is familiar with insulin therapy or he might send you to a diabetes education center or to a CDE pharmacist like myself with to help you start it they have found especially in type 2 diabetes using that long-acting insulin analog like lantus or less lemon air very safe and very easy for a patient to self titrate it is not necessary to go to a endocrinologist if you've been on metformin by itself often they'll try using some kind of a sulfonylurea first if you're only on metformin thank you another question here what are the possible side effects of and I'm gonna butcher it can and glyphs losen someone told me we have to think about that Canada is frozen Koenig lifts both anyways the potential side effects are again excess urinary excretion the dehydration is the big concern with that medication they're also the urinary tract and the genital yeast infections those are probably the most common side effects with that medication thank you thanks for letting me how to pronounce that another question here is it okay to take metformin if your kidney function is low I am also on bolus and basal insulin usually with metformin they usually discontinue that medication if you're in renal failure and they may choose to make that in what they call EGF are of less than 30 or renal failure is actually less than 15 I have seen them take people off of metformin when it gets to that kidney level it really depends on what that kidney function really is and also I hope it's the rest of that question sorry you're on basil and bolus the reason they use metformin along with insulin is they believe it helps keep the dose of insulin to be a little bit less perfect thank you another question here my aunt has diabetes type 2 in her old age passed away at 97 years old but never needed to take insulin this relates to your saying that everyone having type 2 diabetes will eventually have to take insulin there are lots of people that probably can manage it with diet and exercise but is rare I think if you look at it from I've trained I remember my statistics they say I said everybody but they say approximately 60% of people with type 2 diabetes will require insulin though is that if someone who gets diabetes and it's just almost like a pre-diabetes and they're just taking metformin they may never progress past having that is it it's all dependent on what your blood sugar is but I said that because I want everyone to realize that it could eventualities in them because a lot of people think oh no it's the worst thing ever that could happen but I always look at it if someone has low estrogen we give them estrogen if somebody has low testosterone we give the testosterone somebody has low thyroid we give them the thyroid but if something has low influen it seems to be the last thing we think about and I think people are put off of it too long you would feel so much better if only what's necessary if you can control it the other way fine but if you can't I just want you to take away the idea that insulin is a punishment insulin is an excellent treatment thanks for that insight so just a reminder for our participants if you like to ask Eileen a question it's easier for me just to keep track of the questions if you entered it into the Q&A pod on your bottom left-hand corner so the next question is are there charts to guide us on how much insulin to take for corrective action there there is a formula that your diabetes educator can calculate for that if what you're talking about is if I need I'm already on insulin but I my blood Sugar's high how much do I take to bring it down there there is a formula based on what your total daily dose is I don't want to say what it is because I want you guys playing with it by yourselves but you always have to look at it this way you can titrate it based on what your blood sugar is either for a basal insulin what your fasting blood sugar is for a bolus insulin either what your next meal time is or two hours after the meal if two hours after the meal you're less than 10 then you had enough insulin to cover it if your fasting blood sugar is less than 7 your basal insulin is covering it I hope that sort of helped thanks yeah that definitely does the next question is does glycon work exactly the same way as metformin glycon is metformin glycon is just a brand name perfect the next one is januvia and that Foreman is a common combination in therapy these days it is is it common to have self so fond urea bond areas okay add it to this drug regimen it's not unlikely because you're looking at the januvia is that dpp-4 inhibitor so it's keeping that little glp-1 along longer the metformin is slowing down that release of it from the liver so if they don't think that januvia is having enough of an action they're going to add that so funny urea to squeeze your pancreas so fine areas you must have some beta cells left and I I believed in a lot of cases you see people that are on a self on urea for a long time and their blood Sugar's keep going up but yes it can be used with januvia and metformin perfect thank you so again if you guys have any other questions please them type it into the Q&A box on your bottom left-hand corner and as you're listening to the Q&A session and if you have a need if you have two minutes if you would fill out the post survey we would really would love to hear from you and so we can better our program and so we have a couple more questions here is taking Lantis insulin twice a day a good way to control high blood Sugar's before supper I have a person who takes Lantis at bedtime and in the morning timing isn't always the best not always taken at the same time well depending on who you talk to I've been at diabetes conferences it says there's absolutely no reason you shouldn't just take lantus all at one time and sometimes it's split if you taking more than 50 units at a time because that's a large amount of insulin and sometimes it rather than have two shots at one time they'll split it for morning and bedtime the challenge is with your high blood Sugar's before supper really maybe related to mealtime and lantus is a background insulin and in theory if you didn't eat all day and you took lantus or 11:00 there your blood sugar could essentially stay the same because it's not covering meals and some people are getting that high blood sugar before supper because it's what they ate and their lunchtime the medicine they take isn't covering the blood sugar raised from lunch and so that's why they have blood sugar that's high before it suffered if you didn't eat all day and your blood sugar in the morning and twice a day Atlanta then you're fasting would be under 7 and your before supper would be under 7 but because you have meals in between you have to kind of decide what's the challenge it may in fact be the blood sugar from a meal that is causing his high priests upper blood sugar thanks for that explanation and very sore oh so we have another question here januvia indicated for for GFR above 50 trijet a– indicated for all renal patients do you recommend a change from januvia to try jente with renal patients yes that is actually the recommendation for anyone with a decreased renal function to agenda has only about 5% excreted through their kidneys so it is a good choice for anyone with decreased renal function hello we ended oh sorry about that I was still on mute okay hmm okay sorry about that okay so januvia approved for youth with insulin but I have not heard regarding trijet tip part two a question right tooth question well you know I really I'm not sure the answer to that question I will tell you if your new visa proved the whole class is approved and I have seen a few people that are just taking a bad time insulin that are using a dpp-4 inhibitor because of course that dpp-4 inhibitor is trying to help with the meal time as well because it's released in response to your blood sugar if you were on a mealtime insulin as well I'm not certain of the total benefit of sorry I'm not clear on that answer that's okay thanks for trying to answer it with taking Lantis and a short-acting insulin before breakfast help with supper highs surprising not the answer that might be yes again it kind of depends on what's causing that high blood sugar at supper because what they say is if you can get your fasting blood sugar under control then the rest of the day will be better and because a lot of times will suffer for something called a dawn phenomena where you get hormones released in your body that causes your blood sugar to rise naturally in the morning it is one of the reasons why when they're doing that basal plus one dose of fast-acting a meal time that they often will put that meal time at the morning because sometimes that makes the rest of the day fall into place however if the person's at that point where their blood sugar is always high at different times a day then they're probably a candidate to have a second dose of a mealtime insulin thanks for clarifying much so the next question is what is the cost of China goes close in and do you think the government drug plans will pick them up I don't actually recall the cost of Kanaka flows and I don't actually dispense drugs I am just a council so I cannot tell you the exact cost government does not cover new medications at the beginning we'll hope that it does get coverage eventually and I'm sorry I can't remember what it is but I believe someone told me it's around the same price as dpp-4 inhibitors so probably about 70 to 80 dollars a month Thanks and just a comment here this person wants to point out that Victoza is expensive and may not necessarily work for all persons to help with weight loss that's why I pointed out that in the studies with Victoza and glp-1 analogues the actual weight loss was 1.9 kilograms on average there are reports of large amounts of weight loss but I have seen people who take Victoza and do not lose any weight at all perfect thanks so we're coming to an end to the presentation so I'm just going to go through the last couple of slides but if you do think of another question that you'd like to ask Elaine again please type it into the Q&A pod and we'll get to get to it in a little bit just one more comment here this person wants to thank you Elaine for an enlightening session the person learned a lot and didn't expect to learn so much new information oh good thank you oh I'm just going to continue with the slides here so thanks very much to everyone who attended the webinar today not tonight and for all the wonderful volunteers who coordinated this session we'd like to remind everyone that you will be sent in evaluation survey tomorrow and encourage you to complete it it should really only take about two minutes and provides us with very valuable information so this webinar is generously supported by johnson and onetouch and if you haven't seen this already it's the diabetes Charter and we'd like to encourage you to sign it and if you like to sign it or for more information you can go to WWE Diva Artur dot CA and so again the developments and delivery of impactful programs such as our Canadian diabetes webinar series is made possible through the generous support of our donors if you enjoyed the webinar and would like to make a donation please visit us at our website at www.att.com/biz info PC at diabetes at CAA

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