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Understanding Your Oral Medications

E_LAILA 2014

Prof Dr Norlaila Mustafa   Consultant Endocrinologist, Universiti Kebangsaan Malaysia Specialist Centre.

According to Prof Dr Norlaila Mustafa, a consultant endocrinologist who runs a diabetes clinic, oral diabetes medications are designed to help you manage your blood glucose level and currently, there are many types available. Your doctor will prescribe the types of medication that are appropriate for you, depending on your body’s response to insulin as well as other health conditions you may have alongside diabetes.

Diabetes medications do not cure diabetes. Dr Norlaila points out that it is just as important to follow a meal plan and exercise regularly to manage your weight to slow the progress of diabetes and reduce the risk of damage to your brain, kidney, liver, eyes, heart, nerves and more.

5 good medication habits

Dr Norlaila recommends the following:

  1. Follow your doctor’s advice when it comes to monitoring your blood glucose level in order to check your response to the medications prescribed.
  2. Refill your medications when they run out. Diabetes medications should be taken continuously, not just when you are feeling unwell, in order to slow the progression of the disease.
  3. Too busy to take your medication? Download a smartphone app to help you schedule your time.
  4. Do not share your medication with other people. Medicine is one of the few things in life that you should always keep to yourself!
  5. Keep a list of all the medications you are on (write down the name displayed on the packaging) as well as any supplements or alternative medications. This list will be useful during medical emergencies.

Metformin: The frontline against diabetes

According to Dr Norlaila, most diabetes patients are on metformin, for good reasons.

  • Along with proper diet and regular exercise, metformin is effective in helping the patient control his or her high blood sugar level.
  • It can be taken by most type II diabetes patients without experiencing dangerous side effects.
  • It is also affordable, and therefore, can be purchased by most patients without straining their finances.

“Because of its effectiveness on many patients with type II diabetes, doctors usually prescribe metformin as the first option when it comes to treating the disease,” adds Dr Norlaila.

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Metformin is considered by many as a “wonder drug” due to how effective it is. In fact, its discovery changed the way we treat diabetes for the better, improving the quality of life and life expectancy of diabetes patients.

Dr Norlaila goes on to explain that metformin helps you manage your blood glucose level in several ways.

  • Your liver produces glucose, which adds to the glucose you obtain from your meals. Then, metformin helps to decrease the amount of sugar produced by your liver.
  • It also helps to reduce the amount of glucose absorbed by your body during the digestion of food.
  • It helps to improve your body’s sensitivity to insulin, allowing your liver, muscle cells and fat cells to take in more glucose from your blood. This reduces the overall amount of glucose in the blood.

Taking metformin. Metformin is available in tablet and liquid forms. Depending on the severity of your disease, your doctor may recommend taking them 1 to 3 times a day after meals.  There are also extended release tablets in the market, which only requires you to take 1 tablet a day, usually during your evening meal. You should follow your doctor’s instructions, restock your metformin when it runs out and continue to take your metformin even when you are feeling healthy.

Side effects. Like many medications, metformin can potentially cause side effects in certain people. Milder side effects include: diarrhoea, indigestion, bloating and stomach pain, constipation, heartburn, headaches, muscle aches and an unpleasant metallic taste in the mouth. More severe side effects include chest pain and rashes. Dr Norlaila advises that you should alert your doctor if you experience any of these side effects over a prolonged period of time.

Very rarely, a patient with renal failure may develop a potentially fatal reaction to metformin called lactic acidosis. Such patients should take other forms of medication for their diabetes. Besides, metformin may not be suitable for patients with problems relating to the heart, kidneys and liver. Fortunately, Dr Norlaila mentions that there are other alternatives to metformin, termed the second line medications, which may be suitable for them.

Second line medications

Second line medications are those that are given to patients in order to support or complement the effects of metformin for better blood glucose management. They may also be given to patients for whom metformin is cannot be used (contraindicated), perhaps due to side effects, kidney problems and such.

Dapagliflozin: improving blood glucose control

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Dapagliflozin is an interesting drug in that, unlike most diabetes drugs that target the pancreas or and liver, it works on the kidneys. “It helps to reduce blood sugar by increasing the amount of glucose excreted in the urine. It may also help with weight loss and improvement of blood pressure,” explains Dr Norlaila.

To help you gain a better understanding of how this drug works, let us first take a look at the link between glucose and our kidneys.

Your kidneys: it’s not just about urine

The kidneys are the main waste disposal factory in our body, so let us imagine a kidney as a big building. Inside the building are about a million little filtration machines called nephrons. The nephron is the key structure responsible for controlling the amount of substances present in the urine.

The glomerulus is the filtration structure – it makes sure that only the right substances that can fit through its pores will end up in the urine. Glucose is of the right size, so it can pass from a blood vessel through the glomerulus without any difficulty.

Normally, urine contains no glucose because the nephron has a system in check to reabsorb any glucose that passes through the glomerulus filter. What happens is that any glucose that strays into the nephron eventually makes its way to the proximal convoluted tubule.

Lying in wait there are special transporters called “sodium-glucose linked transporter (SGLT)” or “sodium-dependent glucose co-transporter”. Like their name suggests, they absorb glucose back into the blood along with sodium. Just like how there are different models of Proton cars, there are different types of SGLTs, such as SGLT-1 and SGLT-2. SGLT-2 is the main transporter in the proximal convoluted tubule.

“About 90% of the glucose filtered in the nephron is reabsorbed with the help of the SGLT-2,” Dr Norlaila points out. Any remaining glucose that manages to elude the SGLT-2 is “caught” by SGLT-1 in a later, straight part of the proximal tubule.

In the case of a type II diabetes patient, the blood glucose level can be high, so it is a good thing if the glucose that finds its way into the kidneys is not reabsorbed but instead, removed from the body via urine.

This is where dapagliflozin steps in. “The drug inhibits the action of SGLT-2, therefore drastically cutting down the amount of glucose that would be reabsorbed back into the blood stream,” says Dr Norlaila. For someone with diabetes, that is a good thing!

Indirectly, dapagliflozin may also help with weight loss as it reduces the amount of calories stored in the body after each meal as well as to reduce one’s overall sense of hunger. However, it should not be considered as a weight-loss drug. Studies suggest that the drug may also help in reducing high blood pressure.

Taking dapagliflozin. Dapagliflozin can be prescribed alongside metformin, or can also be prescribed on its own. In general, it can be prescribed to patients with any stage of diabetes. Ask your doctor for more information.

Who should not take it? This drug may not be suitable for patients who are pregnant or breastfeeding, having kidney problems, having low salt levels in their body, or those with history of dehydration and have been admitted to the hospital. Check with your doctor for more information.

More second line medications

Dr Norlaila mentions some other common medications for diabetes.

Drug group Examples How they work
Sulfonylurea
  • Glimepiride
  • Glyburide
  • Glipizide
  • Micronized glyburide

Increases the amount of insulin released by the pancreas over a few hours after a meal.

Meglitinides Repaglinide

Increases the amount of insulin released after each meal.

D-Phenylalanine derivatives

Nateglinide

Increases the amount of insulin released after each meal.

Thiazolidinediones

(TZDs)

Pioglitazone

Increases the sensitivity of the body towards insulin.

DPP-4 inhibitors

  • Sitagliptin
  • Saxagliptin
  • Linagliptin

Increases insulin level after a meal while decreasing the amount of glucose produced.

Alpha-glucosidase inhibitors

  • Acarbose
  • Miglitol

Lowers the rate of carbohydrate absorption into the body after a meal.

Bile acid sequestrants

Colesevelam

Helps lower glucose level.

Combination pills are also available, often combining the effects of 2 different medications (for example, metformin and a second level medication) for the purpose of convenience and reducing the number of pills you need to take.

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