Information on diabetic medications

Preface
Diabetic medications
Beware of Hypoglyacemia!
Proper Use of Health Products

Preface

Diabetes is a group of diseases marked by high levels of blood glucose resulting from deficiency in insulin production, insulin action, or both. It is a major chronic disease in Hong Kong. Diabetes may lead to various complications and it is also the major cause of death.

Studies showed that patients on appropriate treatment with satisfactory control may reduce the risk of developing complications by 50 to 70%. Therefore, patients should follow the guidance from healthcare professionals and receive long term therapy, in order to stabilize their blood glucose level and reduce the occurrence of complications.

Diabetic medications

As either high or low blood glucose level can lead to serious health consequences, and different drugs used in diabetes have their unique properties, patients should strictly follow the dosing guidance given by doctor. Most of the drugs used in diabetes are prescription medicines and can only be sold by a registered pharmacy under the supervision of a pharmacist. They can be classified into two categories, namely insulin injection and antidiabetic drugs

(I) Insulin injections

Insulin injection lowers blood glucose level by supplementing the insulin of diabetic patients. Insulin injection can be used in both Type I and Type II diabetes. The injection will usually be used with antidiabetic drugs when treating Type II diabetes. Insulin should not be taken orally as it would be destroyed in the stomach. Currently, only injection forms of insulin are available in Hong Kong. Insulin injection is usually classified by its duration of efficacy:

Type of insulin injections	Precautions
Very short-acting e.g. Humalog, Novorapid	Very short-acting: to be injected 15 minutes before meal or with meal; short-acting: to be injected 30 minutes before meal. Inspect your medication every time before use. It should be clear and colourless. Do not use if it becomes cloudy.
Short-acting e.g. Actrapid, Humulin R
Intermediate-acting e.g. Humulin N, Protaphane	Just before use, roll the vial between the palms gently, or, in case of penfill cartridge, turn it up and down for at least 10 times until the solution disperse uniformly. Inspect your medication every time before injection. It should be uniformly cloudy after rolling/turning, Do not use if solid particle is found or if there is change of colour.
Biphasic e.g. Humulin 70/30, Mixtard, Novomix
Long-acting e.g. Lantus, Levemir	Inspect your medication every time before use. It should be clear and colourless. Do not use if it becomes cloudy. It should not be mixed with other insulin in the same syringe.

Remarks for using insulin injection

There are two types of insulin injections: vial and penfill cartridge. As they have different administration precaution and techniques, patient should consult healthcare professionals on the correct way of administration.
Draw the very-short or short acting insulin first if the patient has to mix it with intermediate-acting insulin.
As the absorption rate of insulin differs in different parts of the body, only inject the insulin according to the sites recommended by the healthcare professionals. However, to avoid tissue damage, patients should inject the insulin at a point slightly different from the previous injection site.
Do not rub or apply heat on the injection site after insulin injection to avoid accelerated pharmacological action which can lead to hypoglycaemia.
Patients using insulin injection should monitor the blood glucose regularly as instructed by healthcare professionals. If low blood glucose is detected, take sugar-containing food immediately.
If the patient misses a dose, he/she should administer a normal dose, instead of a double dose, in the next injection. Report this event to doctor during the follow-up consultation.
Never share the injection device, needle or syringe with other person.

Storage requirements for insulin injection

An unopened bottle of insulin should be stored at 2-8°C in a refrigerator.
Insulin in-use (opened bottle) can be kept at room temperature
Patient should mark the seal opening date as reference on the vial or penfill cartridge of insulin and check the date marked every time before administration. The insulin should be disposed within 28 days or the period as stated on the product after opening.
Patients should not store the insulin at a high temperature, such as inside a car or too close to the body, as insulin will denature under high temperature.

(II) Antidiabetic drugs

In general, except insulin, all other antidiabetic drugs are only indicated for Type II diabetes. There are different types of antidiabetic drugs which lower blood glucose via different pharmacological action. Therefore, they are associated with different side effects and handling precautions.

Medicine	Common side effects	Precaution
Insulin sensitizers
Biguanides e.g. metformin	Nausea, diarrhea	Do not drink alcohol while taking biguanides to avoid the risk of lactic acidosis.
Thiazolidinedione e.g. pioglitazone, rosiglitazone	Mild weight gain, edema, hypoglycaemia*	As rosiglitazone may increase the risk of cardiovascular disease, such as heart disease and stroke, patient with heart failure or history of heart failure should not use this medicine. Rosiglitazone is only indicated for patients with diabetes uncontrolled by other medications.
Insulin secretion stimulants
Sulfonylureas e.g. glibenclamide, gliclazide, glimepiride, glipizide, tolbutamide	Weight gain, hypoglycaemia	Do not delay the mealtime after taking sulfonylureas to avoid the occurrence of hypoglycaemia
Meglitinide e.g. Repaglinide, nateglinide	Weight gain, hypoglycaemia	If meals are skipped, the medication should be skipped
Others
Alpha glucosidases inhibitor e.g. acarbose	Flatulence and bloating, diarrhea	This medicine is not recommended for patients with gastrointestinal problems
DDP-4 inhibitor e.g. sitagliptin, vildagliptin	Upper respiratory tract infection, headache, hypoglycaemia* or gastrointestinal discomfort	Regular assessment of renal function is recommended before and during treatment
Incretin mimetic e.g. exenatide	Nausea, hypoglycaemia	This medicine is not recommended for patients with severe renal disease or severe gastrointestinal disease

*There is a risk of hypoglycaemia for thiazolidinedione and DDP-4 inhibitor, but the incidence is low.

Remarks for using antidiabetic drugs

Take the drug at the time and dose as instructed by doctor. In general, antidiabetic drug should be taken with meal. Once the drugs are taken, do not delay the mealtime.
If you miss a dose, take it as soon as possible unless it is almost time for the next scheduled dose. In that case, skip the missed dose and take the next dose as directed. Do not take double dose

Storage requirements for antidiabetic drugs

Store in cool and dry place.
Unless specified on the label, the medicine should not be stored in refrigerator.
Incretin mimetic injection should be stored at 2-8°C in a refrigerator. It should be refrigerated every time after use.
They should be stored properly in place unreachable by children to avoid accidental ingestion.

Beware of Hypoglyacemia!

Hypoglycaemia refers to abnormal low blood glucose level of the body. Patients may develop the following symptoms:

sweating, shivering, sense of hunger, dizziness and malaise. In severe cases, the patient may be unconsciousness and even coma.

Hypoglycaemia may be seen in diabetic patients. The main reasons include excessive use of insulin or hypoglycaemic drugs, and delay of mealtime after taking these medicines. Irregular mealtime and inadequate food intake increase the risk of hypoglycaemia. It should be noted that some medications like beta-blocker may mask the symptoms of hypoglycemia. Patients should inform their healthcare professionals about their medication history.

Prevention and management of hypoglycaemia

Take the drugs on time.
Take the meals on time.
Carry sugar-containing food, e.g. candies, cube sugar, etc.
Take sugar-containing food or drink immediately when developing early signs of hypoglycaemia.
Patient should notify doctor during follow-up consultation if he/she had experienced hypoglycaemia. This helps the doctor to prescribe the appropriate medication and dosage.
Family member should bring the patient to emergency department if he/she lose consciousness or fall into a coma.

Proper Use of Health Products

There are many health products with claims related to blood glucose regulation available in the market. Public may purchase them in local market or from overseas countries. There were cases reported that public became sick after taking these health products. Some of these products were found to be adulterated with oral antidiabetic drugs which increased the risk of hypoglycaemia after consumption. For details, please refer to “Products found to contain undeclared medicines” of the website of Drug Office, Department of Health.

In fact, there is no cure for diabetes at the time being. Patients should work with family doctors and follow the treatment plan as provided by healthcare professionals to control their disease and prevent complications. Use of health products without health professional’s advice not only may affect the patients’ diabetic control, due to interaction, they may also cause symptoms or even life threatening consequences. Public should consult their family doctors, pharmacists or healthcare professionals before consuming any health products and should not use health products to manage diabetes just because of the claims they made.