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Gila Monster Spit---Seriously? Seriously!!. The Role of GLP-1 Analogs in the Management of Type 2 Diabetes Kim Purifoy, MSN, FNP-C Windy City Wellness, PC Cheyenne 307-634-6095 purifoyks@aol.com . OBJECTIVES. Discuss the difference between Incretin Memetics and
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Gila Monster Spit---Seriously? Seriously!! The Role of GLP-1 Analogs in the Management of Type 2 Diabetes Kim Purifoy, MSN, FNP-C Windy City Wellness, PC Cheyenne 307-634-6095 purifoyks@aol.com
OBJECTIVES • Discuss the difference between IncretinMemetics and Synthetic created hormones. • Discuss the role of GLP 1 in glycemic control. Where does it come from and what does it do? • Review GLP-1 Analogs currently available; to include efficacy, dosing, risk factors, and appropriate population. • Discuss how to use administration devices and select appropriate needle size.. • Review current Guidelines for diagnosis, glycemic control, and algorithm for treatment. (If there is time)
DIABETES IS A GLOBAL ISSUEPROJECTED CASES BY 2030 • NORTH AMERICA 2010: 37.4M 2030: 53.2M • WESTERN PACIFIC 2010: 76.7M 2030: 112.8M • EUROPE 2010: 55.2M 2030: 66.2M • AMERICAS(Ex-US) 2010: 18M 2030: 29.6M • SOUTH AFRICA 2010: 12.1 M 2030: 23.9M • MIDDLE EAST / NORTH AFRICA 2010: 26.6 M 2030: 51.7M • SOUTH-EAST ASIA 2010: 58.7M 2030: 101 M
What Is The Difference?Does it matter?? Not really. Synthetically created hormones • Insulin (pancreas) • Symlin (synthetic Amylin-pancreas) • GLP-1 • HCG • Estrogen • Testosterone • Levothyroxine Incretin Memetics—specific to the gut and specific to glucose control. • GLP-1 (Glucose like peptide 1) • GIP (Glucose dependent insulintropic peptide)
GLP-1 Action Stimulates glucose-dependent insulin release from pancreatic beta cells Decreases glucagon production from pancreatic alpha cells when glucose levels are elevated. The combination of increased insulin production and decreased glucagon secretion reduces hepatic glucose production when plasma glucose is elevated. Diabetics Levels of GLP-1 are decreased. The insulinotropic response to GIP is diminished but not absent. Defective GLP-1 release and diminished response to GIP may be important factors in glycemic dysregulation in type 2 diabetes. May have more effect on Type 1 Diabetics than originally thought!!
EXENATIDE (BYETTA®) • Released in 2005 • Produced and Marketed by Lilly and Amylin • Available in Pen form • 5mcg or 10mcg • Dosed twice a day • Dosed in relation to a meal. • Once a week formulation currently in Phase III Trials ?Trade Name Bydureon®? LIRAGLUTIDE (VICTOZA®) • Released in 2010 • Produced and Marketed by Novo Nordisk • Available in Pen Form • 0.60mg, 1.2mg, or 1.8mg • Dosed once daily • Does NOT have to be dosed in relation to a meal.
EXENATIDE (BYETTA®) Indication • BYETTA is an injectable prescription medicine that may improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program. • BYETTA is not insulin and should not be taken instead of insulin. BYETTA is not indicated to be taken with insulin. BYETTA is not for people with type 1 diabetes or people with diabetic ketoacidosis.
EXENATIDE (BYETTA®) Safety Information • Pancreatitis which may be severe and lead to death. Screen for Pancreatitis, stones in your gallbladder (gallstones), a history of alcoholism, or high blood triglyceride levels. Pain in the abdomen that is severe, and will not go away. The pain may happen with or without vomiting and may be felt going from abdomen through to back. • Hypoglycemia if BYETTA is prescribed with another medicine that can cause low blood sugar, such as a sulfonylurea. The sulfonylurea dose may need to be lowered or discontinued. . • Allergic reaction to exenatide or any of the other ingredients in BYETTA.
EXENATIDE (BYETTA®) • Should not be used in people who have severe kidney problems and should be used with caution in people who have had a kidney transplant. May cause new or worse problems with kidney function, including kidney failure. Check renal function prior to initiating therapy and periodically while on treatment. Discontinue treatment if renal impairment or insufficiency develops • Can cause problems in patients with a history of gastroparesis. Screen for issues of delayed gastric emptying • Should NOT be used in pregnancy. Discontinue immediately once pregnancy is known. Should NOT be used if patient plans on becoming pregnant. • The most common side effects with BYETTA include nausea, vomiting, diarrhea, dizziness, headache, feeling jittery, and acid stomach. Nausea most commonly happens when first starting treatment, but may become less over time. • For ADULT use only. Not studied in children
Dosing Start at 5mcg for 30 days Increase to 10mcg Dose twice a day with meals at least 6 hours apart. Give injection up to 60 minutes before the meal. I find that 30 minutes seems to work the best to avoid nausea side effect Each pen contains 60 doses Show them how to work the pen. EXENATIDE (BYETTA®)
EXENATIDE (BYETTA®) • Decrease meal size by ¼ to ½ right off the bat. • Too close to meal time seems to increase nausea. • PAY ATTENTION to the full signal from the brain NOT the gut. • DO NOT take after the meal. If dose is missed do not make up. Just resume regimen at next dose. • Altoids have been recommended to help with nausea. • Report S/Es or problems right away. • Mild nausea is usually transient and disappears with in 2-3 weeks, but can return when dose is increased
Liraglutide (Victoza®) Indication • Victoza is an injectable prescription medicine that may improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program. • Victoza is not insulin and should not be taken instead of insulin. Victoza is not indicated to be taken with insulin. Victoza is not for people with type 1 diabetes or people with diabetic ketoacidosis.
Liraglutide (Victoza®) Safety Information • Pancreatitis which may be severe and lead to death. Screen for Pancreatitis, stones in your gallbladder (gallstones), a history of alcoholism, or high blood triglyceride levels. Pain in the abdomen that is severe, and will not go away. The pain may happen with or without vomiting and may be felt going from abdomen through to back. • Hypoglycemia if Victoza is prescribed with another medicine that can cause low blood sugar, such as a sulfonylurea. The sulfonylurea dose may need to be lowered or discontinued. . • Allergic reaction to exenatide or any of the other ingredients in Victoza. • Medullary thyroid cancer, or multiple endocrine neoplasia syndrome type 2 (MEN 2). Screen for personal or family history thyroid cancers or MEN2.
Liraglutide (Victoza®) • Should not be used in people who have severe kidney problems and should be used with caution in people who have had a kidney transplant. May cause new or worse problems with kidney function, including kidney failure. Check renal function prior to initiating therapy and periodically while on treatment. Discontinue treatment if renal impairment or insufficiency develops • Can cause problems in patients with a history of gastroparesis. Screen for issues of delayed gastric emptying • Should NOT be used in pregnancy. Discontinue immediately once pregnancy is known. Should NOT be used if patient plans on becoming pregnant. • The most common side effects include nausea, vomiting, diarrhea, dizziness, headache, feeling jittery, and acid stomach. Nausea most commonly happens when first starting treatment, but may become less over time. • For ADULT use only. Not studied in childrem
Liraglutide (Victoza®) Dosing • Start at 0.6mg once daily for 7 days • Increase to 1.2mg once daily • Can increase to 1.8mg once daily • 30 day supply: 0.6mg qd 1 pen, 1.2mg qd 2, 1.8mg qd 3. • Dose once daily. Does not have to be timed to a meal.
Liraglutide (Victoza®) • Decrease meal size by ¼ to ½ right off the bat. • PAY ATTENTION to the full signal from the brain NOT the gut. • Try to take about the same time every day. • Altoids have been recommended to help with nausea. • Report S/Es or problems right away. • Mild nausea is usually transient and disappears with in 2-3 weeks, but can return when dose is increased
Pen Needles---not created equal • 6mm or longer requires a “pinch” up • 5mm or shorter NO pinch up • Straight in. No angle. • Incorrect administration will make a difference in medication absorption • Incorrect administration can leave a mark • Push at a nice slow even rate. • Use needles only once. Do not store with needle on device.
