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Your Guide to Diabetes Medications

• Know your diabetes ABCs• Pharmacists on your healthcare team• Drug research: From test tube to you

A supplement to Diabetes Dialogue, an official publication of the Canadian Diabetes Association

Spring 2007

Your diabetes meds at work

Your medications and you

YOUR GUIDE TO DIABETES MEDICATIONS • SPRING 2007 3

By Arlene Kuntz BSP CDE

ON B E H A L F O F the Canadian Diabetes Association, Diabetes Dia-logue is pleased to present the second annual consumer’s guide todiabetes medications, your premier source for information aboutthe medications used to help manage your diabetes.

Diabetes management is a round-the-clock commitment –whether you manage your type 1 diabetes with insulin, or whetheryou manage your type 2 diabetes with lifestyle modification (includ-

ing physical activity and nutrition) and/or insulin and medications.All of the medica-tions and insulins currently available in Canada that are used to manage diabetes areexplained in detail here – with an explanation of how they work and why your doc-tor might prescribe them, along with important details about how they’re taken.

You’ll also find a wealth of information on issues related to your medication man-agement, including:• optimal treatment targets: blood glucose, blood pressure and cholesterol (page 5);• why you may be prescribed more than one drug to manage your diabetes and its

related complications (page 6);• a handy guide to all the medications used to manage your diabetes, with informa-

tion about how they work, what you should know and their advantages (page 8);• pharmacists on your team: how they can help you manage your diabetes (page 13);

and • how a medication evolves, from concept in the lab to your drugstore’s dispensary

(page 14).

We hope you find your consumer’s guide to diabetes medications practical and use-ful, and we’d love to hear from you with any comments and suggestions you may havefor future editions. Email us at [email protected].

We wish you good health and good reading!

Arlene Kuntz is a pharmacist and Certified Diabetes Educator with Shoppers Drug Mart in Regina, SK. She is also

Chair-elect of the Diabetes Educator Section of the Canadian Diabetes Association.

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“Targeting” your efforts


Reaching blood glucose, blood

pressure and cholesterol targets

is key to preventing complications

BY CYNTHIA N. LANK

T H E C A N A D I A N D I A B E T E S A S S O C I AT I O N

reminds all people with diabetes to know their“ABCs” in order to reduce their risk of devel-

oping the long-term complications of diabetes. At onetime, diabetes management focused primarily on bloodglucose control.We now know that diabetes is a muchmore complicated disease that requires a more compre-hensive approach to treatment.When it comes to dia-betes,ABC stands for the three key treatment targets:

A is for A1C.The A1C test is a simple blood test per-formed at the lab, which measures blood glucose con-trol over the previous 120 days.The goal is 7.0% or lowerin most people, and 6.0% or lower in those in whom itcan be safely achieved. Chronically high blood glucoselevels harm the body’s small and large blood vessels andnerves, and raise the risk of diabetes complications. Inaddition, high blood glucose negatively affects the body’sability to fight infection. High blood glucose raises therisk of every diabetes-related complication.All peoplewith diabetes should have their A1C measured approx-imately every three months.The A1C test is not a sub-stitute for self-monitoring of blood glucose, whichprovides day-to-day information on how blood glucoseresponds to food, medication and activity. Both self-mon-

itoring and A1C tests are needed to provide a clear pic-ture of overall blood glucose control.Your blood glucoselog can provide you with information about how treat-ment may need to be adjusted to improve your A1C.

B is for blood pressure. The goal is 130/80 mm Hgor lower.All people with diabetes should have their bloodpressure measured at every diabetes-related doctor’s vis-it. Blood pressure control plays a key role in preventingcardiovascular diseases such as heart attack and stroke,as well as preventing diseases such as retinopathy (dam-age to the small vessels in the eye) and kidney disease.

C is for cholesterol. The primary goal is LDL choles-terol 2.0 mmol/L or lower. LDL cholesterol is common-ly called “bad” cholesterol, as it tends to deposit on the insidewalls of blood vessels.The deposits are known as “plaque”and over time can narrow the blood vessels and restrictblood flow to different organs and tissues. If the plaquebursts, blood will clot at the site of the plaque, and a heartattack or stroke can result.All adults with diabetes shouldhave a blood test to measure their cholesterol at the timeof diagnosis of diabetes and then at least once a year. In addi-tion to measuring LDL cholesterol, HDL cholesterol(“good” cholesterol), triglycerides and the ratio of HDLcholesterol to total cholesterol should also be measured.These also provide information on cardiovascular risk.

ST U D I E S H AV E C O N C L U S I V E LY S H OW N that peoplewith diabetes can prevent the onset or slow the progres-sion of complications by meeting and maintaining theabove targets. For more information on how to reach thesegoals, see “Your diabetes medications at work,” page 6.

Diabetes DialogueSpring 2007Volume 54, Number 1

Diabetes Dialogue, the official pub-lication of the Canadian DiabetesAssociation, is published quarterly(Spring, Summer,Autumn,Winter).Its mission is to deliver current, reli-able information about diabetes topeople affected by diabetes.

Editor-in-ChiefAmir Hanna MB BCH FRCPCFACP

Editorial Advisory BoardBarbara Cleave RN BSCN CDEMaryann Hopkins BSP CDE

Steve Kelman BSc MBA CFASusan MacDonaldTeresa Schweitzer RN BScN CDEDana Whitham RD CDE

Clinical AdvisorArlene Kuntz BSP CDE

Managing EditorFiona Hendry

Assistant EditorPatti Sayle

Editorial ContributorsRuth Hanley,Toronto, OntarioCynthia Lank, Halifax, Nova Scotia

Art DirectionPeter Enneson Design Inc.

PhotographyDanijela Pruginic

AdvertisingKeith Communications Inc.Telephone: (905) 278-6700

PublisherCanadian Diabetes Association522 University Avenue, Suite 400Toronto, Ontario M5G 2R5Tel: (416) 363-3373Email: [email protected]

Subscriptions1-year subscription and membership $29.951 year subscription only $27.951 year membership only $10.00

For address changes, please contact publisher.

General information about diabetesTelephone: 1-800-BANTING(226-8464)Email: [email protected]

The appearance of advertising inthis publication does not consti-tute endorsement by the Canadi-an Diabetes Association. TheAssociation is not responsible forany representation as to quality,value or effectiveness of any prod-ucts, services or methods in thispublication.

A supplement to Diabetes Dialogue, an official publication of the Canadian Diabetes Association

Your diabetes medications at workWhy your doctor may

prescribe more than one

medication for your diabetes

BY CYNTHIA N. LANK

I N MOST PEOPLE WITH DIABETES, achieving andmaintaining blood glucose, blood pressure and cho-lesterol goals require treatment that combines

lifestyle modification with medications.The following article briefly discusses recommend-

ed approaches to diabetes management; however, treat-ment should always be individualized and will almostcertainly change over time. Speak to your doctor if youhave any questions about your medications or any aspectsof your treatment. Be sure to tell him/her if you aretaking any “natural” or herbal products; these productsmay not be closely regulated or have undergone the rig-orous safety testing required for prescription drugs, andcan contain potent ingredients. Lifestyle changes remainan essential part of achieving all your diabetes targetsand overall well-being.These include achieving and main-taining a healthy weight, regular exercise (both aerobicand resistance exercises), good nutrition, stress man-agement and, of course, quitting smoking.

■ Blood glucose medicationsAS P E O P L E W I T H T Y P E 1 D I A B E T E S cannot producetheir own insulin, they must take insulin every day, bysyringe, pen or pump.The recommended insulin regi-men for most people with type 1 diabetes is known asa basal-bolus regimen, given by multiple daily injec-tions.This involves using intermediate- or long-actinginsulin (such as NPH, glargine or detemir) once or twicea day, plus rapid-acting insulins (such as aspart, lisproor regular) at meals.

As type 2 diabetes involves both insulin resistanceand diminishing insulin production, medications usedto treat type 2 diabetes target these different problems.Some drugs make the body more sensitive to the effectsof insulin, some cause the pancreas to release moreinsulin, some reduce the output of glucose from the liv-er, while others delay the release of glucose from foods.

People with type 2 diabetes often require two or moremedications and/or insulin to achieve blood glucose tar-gets. Despite the best efforts of patients and their diabetescare team, in type 2 diabetes, insulin production and bloodglucose control diminish over time. For this reason, yourphysician will likely make changes to your medicationsand doses as you get older or as your health changes.

Finally, many people with type 2 diabetes would bene-fit greatly from insulin. If you are having trouble reach-ing your blood glucose targets, speak to your doctor about

6 YOUR GUIDE TO DIABETES MEDICATIONS • SPRING 2007

D iabetes medications work best when they’re tak-en exactly as prescribed.Ask your doctor, pharma-

cist or diabetes educator these important questions:question: How often and when do I need to take my

pills and/or insulin?question: Do I take my medications with meals? If so,

do I take them right before each meal or at a certaintime after each meal? (These are particularly signifi-cant questions because some diabetes medicationsare specifically designed to work between or aftermeals.)

question: When should I expect to see a reduction inmy blood glucose levels?

question: What should I do if I miss a dose of my med-ication?

question: Should I expect any side effects? If so, is

there anything I can do to reduce them?question: Do these medications cause hypoglycemia

(low blood glucose levels)? If so, how do I recognize,prevent and treat hypoglycemia?

question: How should I store these medications?question: Are there generic versions of medications

that might cost less?question: Will these medications interact with other

(non-diabetes) prescription medications that I’m taking?question: Will they interact with herbal remedies or

over-the-counter medications, such as cough syrup?question: Can I safely drink alcohol while taking these

medications?question: If I become pregnant, could these medica-

tions be dangerous to my baby? If so, what are myoptions for birth control?

QUESTIONS YOU SHOULD ASK ABOUT YOUR MEDICATIONS


whether starting insulin might be appropriate for you.■ Blood pressure medicationsAC H I E V I N G B L O O D P R E S S U R E TA R G E T S in peoplewith diabetes often requires two or more blood pres-sure-lowering drugs. For this reason, the Canadian Dia-betes Association Clinical Practice Guidelines state thatthe issue of which kind of drug to use first may be lessimportant than the need to use more than one drug.Most people with diabetes should be taking an ACEinhibitor, which not only lowers blood pressure, but alsolowers overall cardiovascular risk.■ Cholesterol medicationIN AUTUMN 2006, the Canadian Diabetes Associationreleased new guidelines for the treatment of lipids (bloodfats such as cholesterol) in adults with diabetes.The drugsof choice to lower LDL are known as statins.These med-ications are highly effective and safe, and most peopleshould be able to reach their LDL target on a statin alone.■ Cardiovascular protectionPE O P L E W I T H D I A B E T E S are at high risk of cardiovas-cular diseases such as heart attacks and stroke. For thisreason, the Canadian Diabetes Association Clinical Prac-tice Guidelines recommend the use of ACE inhibitorsand low-dose ASA for general cardiovascular protectionin most people with diabetes. If you are not already tak-ing these medications, ask your doctor if they would beappropriate for you.

■ “I hate taking all these pills!”FOR MOST PEOPLE WITH DIABETES, medications area reality of diabetes management. If you get discouraged,remember that achieving your targets will reduce yourrisk of complications.You may be able to reduce the num-ber of pills you take, or reduce the dosage of certain pills,if you lose weight, modify some aspects of your diet andadopt (and stick with) a regular exercise program.

If you find you are forgetting to take your pills or ifcost is a problem, speak to your doctor or pharmacistabout ways to simplify your medication regimen. Gener-ic pills are less expensive than brand-name medications,and some combination products are available that notonly reduce the number of pills to take, but also reducepharmacy dispensing charges and overall drug costs.Once-a-day long-acting formulations of some medica-tions also simplify medication regimens. A medicationdispenser called a dosette (available at any pharmacy)can help you keep track of what pills to take and when.Many pharmacies offer blister-packaging services (whereall pills taken at a certain time of day are combined intoseparate “bubbles”) to help you take the correct amountof your medications at the right time of day.

Finally, if you are bothered by side effects, speak to yourdoctor or pharmacist. Many people simply stop taking thepills, but many side effects can be managed by changingthe dose or the timing of when you take the pill.

MEDICATION MANAGEMENT

L ife can be hectic, and staying on top of your medica-tion schedule requires special attention. Here are a

few ideas that might help:■ Make sure you understand each medication you’retaking and why you’re taking it. If you’re not certain, askyour doctor, pharmacist or diabetes educator to explain.■ Find out what side effects might be associated withyour drugs, and which symptoms should be reported.■ Never stop taking a prescribed medication withoutchecking with your healthcare provider, even if you don’tfeel any effect from it. Many drugs, especially blood pres-sure or cholesterol pills, make a difference you usuallycan’t detect.■ Deal with one pharmacy for all your medications, andbe sure to talk to your pharmacist before taking anydrugs, including over-the-counter (non-prescription) and

herbal products.This will help prevent medication-relat-ed problems, such as drug interactions, and lead to a clos-er relationship with your pharmacist – an accessible andvaluable healthcare resource.■ Use a pill box/dosette to help you organize your daily/weekly pills.

You may need to try several combinations of medicationsat different dosages to find what works best for you.Speak with your doctor, pharmacist or diabetes educa-tor if you’re having trouble remembering to take yourmedications or if you’re bothered by side effects. Med-ications will only work if you take them, and your doc-tor, pharmacist and diabetes educator can help you findthe simplest, most effective treatment.

BIGUANIDES■ Medication in this class Metformin is the only medication in this class that’savailable in Canada. It’s sold as a generic drug andunder the brand names Glucophage and Glumet-za, the latter of which is a slow-release form ofthe medication.■ How this medication worksThis drug acts mainly by helping the liver reduceglucose production. It also helps muscles use glu-cose from the bloodstream. Both of these actionsreduce blood glucose levels.■ AdvantagesMetformin is the recommended pill for most peo-ple with type 2 diabetes and is especially recom-mended for individuals who are overweight.Metformin does not cause weight gain or hypo-glycemia and works well in combination with someother diabetes pills and insulin.There is some evi-dence that metformin can reduce the risk of heartproblems in overweight patients and improve lipid(blood fat) levels.■ What you should knowThis medication may cause nausea, diarrhea and gaswhen you start taking it.Taking the pills with mealsand increasing the dose slowly can reduce these sideeffects. In some people, metformin can affect theabsorption of both folic acid and vitamin B12. If yourfolic acid or B12 levels are low, your doctor will rec-ommend a supplement.

In addition, if used in people with significantheart, kidney or liver problems, metformin cancause a very rare but serious condition called lac-tic acidosis.

INSULIN SENSITIZERS■ Medications in this classThere are two medications in this class: rosiglita-zone, which is sold under the brand name Avan-dia, and pioglitazone, which is sold under the brandname Actos.■ How these medications workThese medications increase the body’s sensitivityto its own insulin, allowing the cells to use glucosemore efficiently.These pills are recommended in

HOW TO USE THIS GUIDE• Find the name of your medication(s) in

the list below (both generic and brandnames are listed).

• Turn to the page beside your medicationname. Each medication belongs to a drugfamily, or class. Medications that havesimilar actions in the body are grouped inthe same drug class.This guide providesinformation on drug classes, as well as on the medications within each class.

My prescription …turn tolabel says … pageAcarbose . . . . . . . . . . . . . . . . . . . . . . . . .10Actos . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Amaryl . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Avandamet . . . . . . . . . . . . . . . . . . . . . . .10Avandaryl . . . . . . . . . . . . . . . . . . . . . . . .10Avandia . . . . . . . . . . . . . . . . . . . . . . . . . . .8DiaBeta . . . . . . . . . . . . . . . . . . . . . . . . . . .9Diamicron . . . . . . . . . . . . . . . . . . . . . . . . .9Diamicron MR . . . . . . . . . . . . . . . . . . . . . .9Euglucon . . . . . . . . . . . . . . . . . . . . . . . . . .9Gliclazide . . . . . . . . . . . . . . . . . . . . . . . . . .9Glimepiride . . . . . . . . . . . . . . . . . . . . . . . .9Glucobay . . . . . . . . . . . . . . . . . . . . . . . . .10GlucoNorm . . . . . . . . . . . . . . . . . . . . . . .10Glucophage . . . . . . . . . . . . . . . . . . . . . . . .8Glumetza . . . . . . . . . . . . . . . . . . . . . . . . . .8Glyburide . . . . . . . . . . . . . . . . . . . . . . . . .9Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . .11Metformin . . . . . . . . . . . . . . . . . . . . . . . . .8Nateglinide . . . . . . . . . . . . . . . . . . . . . . .10Orlistat . . . . . . . . . . . . . . . . . . . . . . . . . .11Pioglitazone . . . . . . . . . . . . . . . . . . . . . . . .8Prandase . . . . . . . . . . . . . . . . . . . . . . . . .10Repaglinide . . . . . . . . . . . . . . . . . . . . . . .10Rosiglitazone . . . . . . . . . . . . . . . . . . . . . . .8Starlix . . . . . . . . . . . . . . . . . . . . . . . . . . .10Xenical . . . . . . . . . . . . . . . . . . . . . . . . . .11

Note: Generic drug companies often place a prefix at

the beginning of drug names, for example,Apo, Novo,

Gen or Ratio, among others.To find your medication on

this list, remove the prefix; for example,“Apo-glyburide”

would be found under the listing ”Glyburide.”


Your guide to diabetes medications


combination with other diabetes pills. For peoplewho are overweight and unable to reach their bloodglucose targets, the Canadian Diabetes Associa-tion’s Clinical Practice Guidelines recommend aninsulin sensitizer in combination with metformin.For individuals who have very high blood glucoselevels when they’re diagnosed, the guidelines rec-ommend this combination as the initial treatment.■ AdvantagesInsulin sensitizers do not cause hypoglycemia (lowblood glucose levels). New evidence suggests thatinsulin sensitizers can possibly reduce the risk ofheart disease.As well, a major clinical study calledADOPT (A Diabetes Outcome Progression Tri-al) recently determined that rosiglitazone, whenused by people newly diagnosed with diabetes,can help them maintain blood glucose controllonger than glyburide or metformin.■ What you should knowIt can take two to three months for insulin sensitiz-ers to reach full effectiveness.Take the pills exactlyas prescribed, even if there is no immediate improve-ment in your blood glucose. Many doctors try oth-er medications before prescribing an insulin sensitizer,because insulin sensitizers are more expensive thanother diabetes pills. However, there is evidence thatthese pills have the most benefit if taken earlier, ratherthan later, in the course of type 2 diabetes.

Insulin sensitizers can cause fluid retention andincrease total body fat, thereby contributing toweight gain. People with congestive heart failuremust not take these medications.The use of insulinsensitizers in people who already take insulin isnot an approved combination in Canada.The com-bination is approved in the United States, howev-er. If your doctor prescribes insulin and an insulinsensitizer in combination, he or she will explainthat there may be an increased risk of fluid reten-tion or congestive heart failure and may monitoryour health for any early changes.

A few cases of macular edema (swelling of theretina in the area responsible for central vision)have been reported with rosiglitazone.The risk ofthis happening is very low. In most cases, the con-dition improved or returned to normal when the

dose was reduced or the drug was stopped. If younotice a change in your vision after starting aninsulin sensitizer, inform your doctor and haveyour eyes checked.

INSULIN SECRETAGOGUESAlthough these pills are commonly prescribed fordiabetes, the Canadian Diabetes Association’s Clin-ical Practice Guidelines recommend them only asa third choice.The Association recommends thatfor most people, metformin and insulin sensitiz-ers should be tried first.

Insulin secretagogues fall into two classes: sul-fonylureas and non-sulfonylureas.■ How these medications work Secretagogues work by stimulating the pancreas tosecrete more insulin.All secretagogues reduce bloodglucose levels equally well, except for Starlix. (Seebelow.)

SULFONYLUREAS■ Medications in this class There are three medications in this class that are soldin Canada: glyburide (sold as a generic and underthe brand names DiaBeta and Euglucon), gliclazide(sold as a generic and under the brand names Diami-cron and Diamicron MR) and glimepiride (soldunder the brand name Amaryl).Two other drugs,chlorpropramide and tolbutamide, are available inCanada but are rarely used.■ How these medications differ from one

anotherThese medications work in the same way, but dif-fer in how long they take to work. Amaryl andDiamicron MR are long-acting and need to be tak-en only once a day. Compared with glyburide (alsolong-acting), they cause less weight gain and lesshypoglycemia. Glyburide is more likely to causeweight gain and very low blood glucose levels(hypoglycemia); it is not the medication of choicefor people who are at high risk of hypoglycemia(such as the elderly).■ What you should knowAll of the sulfonylureas can cause hypoglycemia;however, there is usually less risk using gliclazide

or glimepiride. If you are taking a sulfonylurea,learn how to recognize, prevent and treat lowblood glucose levels.

NON-SULFONYLUREAS■ Medications in this class There are two medications in this category thatare available in Canada: repaglinide (sold underthe brand name GlucoNorm) and nateglinide (soldunder the brand name Starlix).■ How these medications workLike the sulfonylureas, non-sulfonylureas work bystimulating the pancreas to secrete more insulin;however, they are designed to do this for four tofive hours, just covering mealtimes.■ AdvantagesNon-sulfonylureas work quickly and lower bloodglucose levels after a meal.They are especially use-ful for people who have irregular meals, such as shiftworkers, and for those whose blood glucose levelstend to be high after meals.As well, they are lesslikely to cause hypoglycemia than sulfonylureas.■ What you should knowBoth GlucoNorm and Starlix need to be takenwith every meal, which can be challenging forsome people. If you have to skip a meal, do nottake the pill planned for that meal. As hypo-glycemia is a risk, people taking this medicationneed to learn how to recognize, prevent and treatlow blood glucose levels.

The main difference between GlucoNorm andStarlix is that Starlix reduces blood glucose to alesser degree than GlucoNorm.

COMBINATION PILLSCombination pills, which mix common diabetesmedications into a single pill, reduce the numberof pills you need to take.They can also save youmoney because you pay only one pharmacy dis-pensing fee.The fixed combination of doses, how-ever, means there is less flexibility to tailor dosagesto individual needs.

The combination pills currently available inCanada are Avandamet (rosiglitazone and met-formin) and Avandaryl (rosiglitazone and glime-

piride).They are available in several fixed-dosecombinations.

ALPHA-GLUCOSIDASEINHIBITORS■ Medication in this classThe only medication in this class is acarbose, soldunder the brand name Glucobay (it was former-ly called Prandase).■ How this medication worksGlucobay lowers blood glucose levels after meals.Taken with the first bite of a meal, Glucobayworks in the intestine to block an enzyme thatbreaks down complex carbohydrates (such as thosefound in bread and potatoes) into glucose, whichis a simple carbohydrate. This slows down theabsorption of glucose from these foods, giving thepancreas more time after meals to secrete enoughinsulin to lower blood glucose levels.■ AdvantagesGlucobay does not cause hypoglycemia and thereare no serious side effects. One major study hasshown that the medication can help prevent thedevelopment of diabetes in people with predia-betes. It can be used in combination with otheroral diabetes medications and with insulin.■ What you should knowGlucobay can cause unpleasant side effects suchas gas, bloating and flatulence.To reduce these sideeffects, a low starting dose can be prescribed, andthen the dose can be slowly increased. AlthoughGlucobay won’t cause hypoglycemia, many peo-ple who take it also take other diabetes medica-tions that can cause hypoglycemia.

If hypoglycemia develops while taking Glucobay,it must be treated with dextrose tablets, honey ormilk. Because of the way Glucobay works, sometypical treatments for hypoglycemia – such as tablesugar, regular soft drinks or fruit juice – are noteffective. People with chronic intestinal diseaseand kidney failure should not take Glucobay.

ANTIOBESITY DRUGS■ Medication in this classAlthough there are other weight-loss medications,




only orlistat (sold under the brand name Xenical)is approved for the treatment of diabetes in peo-ple who are obese.■ How this medication worksXenical is taken with meals and works in the intes-tine to decrease the absorption of the fat from foods.The undigested fat is then eliminated in the feces.■ AdvantagesXenical is typically recommended for individualswho are obese and as part of a strategy to loseweight and avoid regaining lost weight, whileimproving blood glucose levels.■ What you should knowMost people who take Xenical lose modest amountsof weight if they also reduce their caloric intake andadopt a regular exercise program.The medicationis not a replacement for a healthy meal plan andregular activity.Those who take Xenical must fol-low a low-fat diet and divide their fat, carbohydrateand protein intake over three meals per day.

With a high-fat diet, excess fat in the intestinecan result in fatty or oily stools or even in theinability to control bowel movements.

This medication can reduce the absorption ofsome vitamins, so taking a multivitamin daily isusually recommended. Although Xenical isapproved as a medication to lower blood glucoselevels, its effect is modest. Because of its weight-loss and blood glucose-lowering effects, though,Xenical can help some people with prediabetesavoid developing diabetes.

INSULINSPeople with type 1 diabetes require insulin everyday of their life. People with type 2 diabetes oftenneed insulin to help them meet their blood glu-cose goals. In type 2 diabetes, insulin can be tak-en alone or with diabetes pills.

Insulins are classified by their duration of action(how long they work).They also differ in theironset of action (how quickly they start working)and when this action peaks (when they are mosteffective). Insulin is measured in units. By under-standing how your insulin works, you can timeyour meals, snacks and exercise. If you take insulin,

you need to monitor your blood glucose levels reg-ularly. (See chart on page 12 for more informa-tion on the various insulins available in Canada.)

The insulin regimen your doctor prescribeswill depend on your treatment goals, lifestyle,diet, age, general health, risk of low blood glu-cose, your preference and financial circumstances.

The goal of any insulin regimen is to mimic, asclosely as possible, insulin secretion in peoplewithout diabetes. In people without diabetes, thepancreas provides a constant supply of insulin(called basal insulin) and secretes extra insulinwhen needed, such as when you eat (called bolusor meal insulin).Your insulin regimen, therefore,will have a basal component to provide some lev-el of insulin at all times, as well as a bolus com-ponent to manage blood glucose over mealtimes.

The best way to learn about insulin is by con-sulting a diabetes educator.Ask your doctor for areferral. A diabetes educator will help you learnabout injection options (syringes, jet injectors,pens, pumps), how to adjust your insulin dosebased on your blood glucose monitoring results,how to time your meals and snacks, how to matchyour carbohydrate intake to your insulin dose, theeffects of exercise, and how to care for and storeyour insulin. Importantly, you will learn how toprevent, recognize and treat low blood glucoselevels (hypoglycemia).

Many people with type 2 diabetes resist takinginsulin.They feel that taking insulin means thatthey’re sick or have somehow “failed” to managetheir diabetes. Needing insulin does not mean thatyou have failed in any way. Some people find it help-ful to think of insulin therapy as a natural hormonereplacement therapy. In other words, insulin injec-tions simply replace a natural hormone that the bodycan no longer produce in sufficient quantities.

Other individuals resist taking insulin becausethey’re afraid of needles or feel it will be embar-rassing to give themselves injections in public.Insulin pens are an excellent alternative tosyringes; they’re virtually painless and can be useddiscreetly. Also, using an insulin pen can helpreduce dosing errors.

*Novolin ge 10/90 and 20/80 will not be available after July 2007. Please visit www.novonordisk.ca for further information.



Brand names(generic name in brackets)

Humalog (insulinlispro) NovoRapid (insulinaspart)

Humulin-R Novolin ge Toronto

Humulin-NNovolin ge NPH

Lantus (insulinglargine)Levemir (insulindetemir)

Humalog Mix 25Humulin (20/80,30/70)Novolin ge (10/90,*20/80,* 30/70, 40/60,50/50)

Insulin type/action(appearance)

Rapid-acting analogue (clear)Onset: 10–15 minutes Peak: 60–90 minutes Duration: 4–5 hours

Short-acting (clear)Onset: 0.5–1 hour Peak: 2–4 hours Duration: 5–8 hours

Intermediate-acting (cloudy)Onset: 1–3 hours Peak: 5–8 hoursDuration: up to 18 hours

Extended long-acting analogue (clear and colourless)

Onset: 90 minutesPeak: none Duration: 24 hours

Premixed (cloudy)A single vial contains a fixed ratioof insulins (the numbers refer tothe ratio of rapid- or short-actingto intermediate-acting insulin in the vial)

Basal or bolus?

Bolus

Bolus

Basal

Basal

Combinationof basal andbolus insulins

Dosing schedule

Usually taken rightbefore eating, or tolower high blood glucose levels

Taken about 30 min-utes before eating, orto lower high bloodglucose levels

Often taken at bed-time, or twice a day(morning and bed-time)

Usually taken onceor twice a day

Depends on thecombination

☛ A1C: 7% or lower.(Some people with diabetes aim for 6% or lower,but this should be your target only if you and yourdoctor feel you can achieve it safely.)

☛ Blood glucose level before meals: 4 to

7 mmol/L (or 4 to 6 mmol/L if your target A1C is6% or lower).

☛ Blood glucose level 2 hours after meals:5 to 10 mmol/L (or 5 to 8 mmol/L if your targetA1C is 6% or lower).

TYPES OF INSULIN

BLOOD GLUCOSE TARGETS

Pharmacists on your teamWhat can they do for you?

BY RUTH HANLEY

T H E L A S T T I M E you picked something up at apharmacy, did you pick up some informationwhile you were there? If you didn’t, you’re

missing out on a great resource.Pharmacies offer the latest drug information, of course

– but that’s just part of the information service they canprovide. Pharmacists can also help you interpret infor-mation you’ve found in other places, such as mailings,magazines or the Internet. “Rather than a dearth of infor-mation, people today are drowning in information,” saysMorna Cook, a community pharmacist in Winnipeg andwinner of the Canadian Diabetes Association’s 2006National Volunteer of the Year Award. “They need some-body on their team, somebody to sort it all out.”

Sometimes people simply don’t understand the infor-mation provided – but other times the information canbe downright “murky,” says Cook, whether it’s over-tech-nical or oversimplified, or just plain misleading. Cookrecalls one woman who came to her concerned aboutsome promotional material she had received in the mailabout her meter.“She thought there was something wrong:that her meter was being recalled, that all her numberswere wrong, or maybe she didn’t have diabetes at all!”

Pharmacists also play an important role in reinforcinginformation you’ve already received about your treatmentfrom other members of your healthcare team.And becauseyou’re probably in and out of the pharmacy on a regularbasis picking up supplies and medications, it’s easy for youto get that information when you need it, rather than tak-ing it all in at once. “We have a ton of information aboutdiabetes,” says Cook. “But if I blast that at the person all atonce, they’re absolutely overwhelmed and, when theycome to need it, they’ve forgotten about it.They need toknow that, when the time is right for them, this is one ofthe places for understandable, personalized information.”

It may be a case where the pharmacist realizes youneed more information even though you think you’redoing just fine. “It doesn’t matter if you know what yourblood glucose reading is, if you have no idea what to doabout it,” says Cook. She points to her own brother, whohas diabetes and was having trouble getting his diabetes

under control. She looked at the memory in his meterand discovered that he never tested at night.When sheasked why, he explained, “I’m always high then, so Idon’t bother testing.”

Pharmacists probably see you more often than any oth-er healthcare professional on your team, and they havethe expertise to pick up on little signals that could pointto a bigger problem. For example, they might ask youquestions because they’ve noticed that you’re picking upPolysporin antibiotic cream twice in one week (possiblefoot injury), or buy a bottle of Maalox antacid every timeyou pick up your prescription (possible stomach prob-lems).They may suggest that you visit your doctor or, ifyou wish, may talk to the doctor on your behalf.

That advocacy role is important, because some peo-ple present a falsely positive front to their physician, saysCook. She recalls one patient who had terrible breathbecause of gum problems. Her dentist didn’t know shehad diabetes – and her doctor didn’t know she was “fudg-ing” the results of her blood glucose readings because shedidn’t want the doctor to know her diabetes wasn’t undercontrol.The problem got fixed because Cook and thedoctor were brainstorming about medical reasons for thepatient’s bad breath, and Cook asked if he had double-checked the patient’s monitor results lately. “For somereason, people think of the doctor on a different level, asjudgmental,” says Cook, “whereas very few people have‘white coat syndrome’ with pharmacists.”

As well as working with other healthcare profession-als on your behalf, pharmacists can also connect you withlocal support groups, or help you navigate your waythrough government drug benefit and private insuranceprograms.They can also be information clearinghousesfor brochures or seminars on diabetes (some provide dia-betes education programs themselves), and for supplierssuch as MedicAlert or orthotics manufacturers.

In order for your pharmacist to provide the best care,you need to do your part too, says Cook. “It’s importantthat you deal with somebody who is acquainted with yourentire healthcare profile.” Make sure the pharmacist knowsabout all of your health conditions and allergies, and alwaysuse the same pharmacy whether you’re purchasing dia-betes supplies, herbals, vitamins, or prescription or over-the-counter medications – that makes it easier for pharmacystaff to pick up on potential problems such as interactions.

Keep a logbook of your blood glucose levels and medications, andreview the results regularly with your healthcare professional.

tip

Drug researchFrom test tube to you

BY CYNTHIA N. LANK AND RUTH HANLEY

T H E P RO C E S S O F D E V E L O P I N G a new med-ication is extremely long and expensive, andtypically follows more or less the same pattern.

First, scientists study chemical and physical processesthat occur at the level of genes, molecules and cells, inorder to better understand the “pathways,” or processes,involved in a certain aspect of a disease.They then con-duct experiments to test their theories on laboratory ani-mals or in isolated cells. Next come tests on ways to alterthe processes that appear to be contributing to the devel-opment of the disease or enhance processes that may offerprotection against the disease.

These interventions are then studied in animal mod-els. If a given intervention is found to be safe and effec-tive, researchers conduct a series of studies, in whichthe suggested treatment is used in ever-larger groupsof people.These studies must adhere to strict ethicalguidelines to ensure the safety of the volunteers whoare willing to try experimental treatments.These trialsare specifically designed to detect any potential safetyproblems as well as the effectiveness of the treatment.

Finally, drugs must be approved for use and sale inCanada by Health Canada, the government agency thatspecifies exactly how and in whom the drug may beused. In addition, ongoing evaluations are required tocollect safety data over the long term after a drug islaunched. If serious or frequent side effects are discov-ered, a drug will be taken off the market.

INTERPRETING THE RESULTS OF DRUG TRIALSAT E AC H S T E P I N T H E P RO C E S S , drug trial resultsare studied by other researchers and clinicians.Theyneed to know whether the trial was properly designedand results were correctly interpreted. Ideally, trialsshould be replicated by other researchers to ensure thatthe same results will occur. Consumers also need tobecome “scientifically literate” if they want to be ableto understand what trial results truly mean.

Here are a few examples of questions you shouldthink about when reviewing a trial’s results.

■ Design: Was the trial double-blinded (meaning bothpatients and researchers were unaware which treatmentthe patient was receiving, to ensure they didn’t subcon-sciously favour one over the other)? If the trial comparesthe study drug to another drug, is it a fair comparison?How long did the trial last? In earlier stages of testing, thedrug may be tested for a short period, but in later stages,it should be tested over several months or even years tosee whether the drug remains useful or causes dangerousside effects when used for a long period of time.■ Researchers: Who is working on the trial and whois providing financial support? Many drug trials are spon-sored by the drug’s manufacturer; there is nothing intrin-sically wrong with this, since the company naturallyneeds to ensure that its product is effective and safe.However, it is essential that the design of the trial doesnot somehow favour the company’s product.■ Subjects:Who was enrolled? If they’re people whohave the disease being treated, but who are otherwisehealthy, will the trial results be applicable in the real world,where patients may have more than one health problem?■ Results: Numbers can mean a lot of things, depend-ing on how they’re interpreted. For example, a studymight show that 50 per cent of the people in the activetreatment group were cured.That might sound amaz-ing, until you read further and find that 40 per cent ofthose in the placebo group were also “cured.”■ Reporting of results: Bias can creep in, intention-ally or not, when study results are reported. For exam-ple, researchers might report on the beneficial effects oftheir drug at the six-month stage of the trial, but not reportat the 12-month stage, if the results are not as beneficial.■ News media: General reporters may not be qual-ified to accurately report on the intricacies of a clinicaltrial; also, they may oversimplify their report becausethey want to grab the consumer’s attention with a dra-matic headline, or cram a lot of complex informationinto a very small story.

It’s clear that interpreting the results of a clinical trialis not an easy matter.That’s why it’s important, if you’veheard about a clinical trial that seems to have exciting impli-cations for you, to discuss it with a healthcare profession-al you trust. He or she can review the information and helpyou determine whether the results are as exciting as theyseem to be.

Make and keep appointments with your dietitian, an importantmember of the diabetes healthcare team.tip

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