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    Learning About Your Health

    Diabetes: Taking Medications Safely

    Pills for Diabetes

    Your doctor may order one or more medications in pill form to control your diabetes. These medications do not contain insulin. These medications are divided into several different groups. Each section below lists the group of medication and how it works. Do not hesitate to ask questions regarding these medications (or ones not listed) with your doctor, pharmacist or diabetes educator.

    Insulin Secretogogues make the pancreas release insulin.
    Brand Name (Generic Name)Dose RangeWhen to Take
    Micronase®, Glynase®, DiaBeta® (glyburide) 1.5 - 20 mg 1 - 2 times a day with meals
    Glucotrol® (glipizide) 5 - 40 mg 1 - 2 times a day, 30 minutes before a meal
    Glucotrol® XL (long-acting glipizide) 2.5 - 20 mg Take once a day with breakfast
    Amaryl® (glimepiride) 1 - 8 mg Take once a day with a meal
    Prandin® (repaglinide) 0.5 - 2 mg Take up to 3 times a day right before a meal
    Starlix® (nateglinide) 60 or 120 mg Take up to 3 times a day right before a meal

    Considerations:
    • Risk of hypoglycemia


    • May cause prolonged hypoglycemia in elderly patients or those with kidney disease


    • Do not crush or break Glucotrol® XL pills


    • Possible weight gain


    • Possible rash


    • Do not take if you skip a meal

    Alpha-Glucosidase Inhibitors slow the absorption of carbohydrates in the intestines.
    Brand Name (Generic Name)Dose RangeWhen to Take
    Precose® (acarbose)25 - 300 mgWith first bite of a meal, up to 3 times a day
    Glyset® (miglitol)50 - 300 mgWith first bite of a meal, up to 3 times a day

    Considerations:
    • If used with insulin or insulin secretogogues, treat hypoglycemia with pure glucose as Precose® can interfere with absorption of carbohydrates


    • May cause bloating, gas and diarrhea

    Thiazolidinediones decrease insulin resistance.
    Brand Name (Generic Name)Dose RangeWhen to Take
    Actose® (pioglitazone)15 - 45 mg Once a day, same time every day, with or without food

    Considerations:
    • Risk of swelling and weight gain


    • When used with insulin or with people who have congestive heart failure, these medications may increase risk of heart issues

    DPP-4 Inhibitors lower blood glucose when it is high, especially after a meal. Stops working when glucose is normal. Decreases glucose production in liver.
    Brand Name (Generic Name)Dose RangeWhen to Take
    Januvia® (sitagliptin)25 - 100 mgOnce a day with or without food
    Onglyza® (saxagliptin)2.5 mg or 5 mgOnce a day with or without food
    Tradjenta® (linagliptin)5 mgOnce a day with or without food

    Considerations:
    • Risk of hypoglycemia if combined with a sulfonylurea


    • Risk of headache or stomach discomfort and diarrhea


    • Possible side effects of stuffy/runny nose, sore throat, upper respiratory infection, headache

    Biguanides decrease glucose production from the liver.
    Brand Name (Generic Name)Dose RangeWhen to Take
    Glucophage® (metformin) 500 - 2,500 mg Take with a meal
    Glucophage® XR (metformin long-acting) 500 - 2,500 mg Take with a meal

    Considerations:
    • You may not experience the full effect for about 2 weeks


    • Take with food to minimize risk of diarrhea and nausea. Tell your health care provider if these symptoms do not go away


    • If you drink alcohol or have kidney or liver disease, ask your health care provider about the safety of taking metformin in any form

    Combination Drugs
    Brand Name (Generic Name)Dose RangeWhen to Take
    Glucovance® (glyburide/metformin)20/2,000 mgBefore a meal
    Metaglip®(glipizide/metformin)20/2,000 mgBefore a meal
    Janumet® (sitagliptin/metformin)100/2,000 mgWith a meal

    Considerations:
    • Refer to individual medications listed above

    Dopamine Agonist Keeps the liver from releasing too much glucose; improves muscle sensitivity to insulin.
    Brand Name (Generic Name)Dose RangeWhen To Take
    Cycloset® (bromocriptine mesylate)0.8 mg daily, increase weekly by 1 tablet until 1.6 to 4.8 mg reachedWithin 2 hours of waking up in the morning with food

    Considirations:
    • Nausea common at first; slowly increase dose as directed


    • Headache


    • Do not use with certain migraine medications

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    Insulin Injection

    Insulin is a hormone that lowers blood glucose. Insulin can not be taken as a pill because stomach enzymes destroy it before it can work. This section is about using insulin safely. This means knowing how to draw up and inject insulin as well as knowing how different insulins work (specifically, action and timing).
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    How to Draw up Insulin (Vial and Syringe)

    1. Wash your hands and gather your supplies.


    2. If you take cloudy insulin, roll the bottle between your hands until the insulin is evenly cloudy.





    3. Clean the top of the bottle with an alcohol wipe.







    4. Note the amount of insulin you will need. Pull the plunger until you fill the syringe with that amount of air.










    5. With the bottle right side up, push the needle into the rubber stopper on top of the bottle and push the air in the syringe into the bottle.










    6. Turn the bottle upside down with the syringe still in the rubber stopper.









    7. Slowly pull the plunger to fill the syringe with insulin. To get the right number of units, make sure that the top of the black
      plunger is lined up to match the number of
      insulin units needed.


    8. Look for air bubbles. If there are air bubbles in the syringe, that means you will not be getting the right amount of insulin. If you see air bubbles in the syringe, push the insulin back into the bottle (do not pull out the needle) and start over from Step 7.


    9. When you have the correct number of units in the syringe, pull the needle out of the rubber stopper.

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    How to Inject Insulin

    1. Clean your skin where the injection is to be made. You may use soap and water or an alcohol wipe. Make sure your skin is completely dry before you inject. Use the abdominal area (unless otherwise advised) as insulin is most evenly absorbed in this area. Change the site on the abdomen for each injection. Stay an inch or more away from your navel with each injection. (See Figure A below, Where to Inject Insulin Safely.)


    2. With one hand, gently gather a small fold of skin. Do not pinch up your skin unless you have a 1-inch needle; most needles are small and do not require you pinch up the skin.


    3. Pick up the syringe with the other hand and hold it the same way as you would hold a dart. Do not let the needle touch anything. Insert the needle straight into the skin. Be sure to insert the needle all the way. It is best for most people to use a 90 degree angle to inject insulin.


    4. To inject the insulin, push the plunger all the way down and hold for five seconds.


    5. Pull the needle straight out of the skin.


    6. If necessary, you may press your finger or an alcohol swab over the spot where you gave your injection, but do not rub the area.


    7. Place the syringe with the needle into a sharps container according to the instructions in Monitoring. Never recap a needle!



    Figure A Where to Inject Insulin Safely (abdomen but not around the navel, upper arm and thigh, hip and buttock)


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    How to Use an Insulin Pen

    1. Wash your hands and gather your supplies.


    2. Clean your skin (see Step 1 of How to Inject Insulin above).


    3. Peel back the paper cover on the needle, and attach the needle to the pen by screwing it into place.


    4. Do an “air shot” to make sure the pen works. Turn the dial to 2 units. Push the bottom of the dial (end of the pen) all the way in. Check that the insulin has come out of the needle tip. If not, repeat the air shot.









    5. Make sure the dial goes back to zero (“0”). It is very important to do this step each time you take a shot and to use a new needle each time.




    6. Dial the pen to the amount of units needed.


    7. Follow the steps on How to Inject Insulin above (only press the dial to deliver your injection). See manufacturer recommendations for how long to hold the plunger down and how to store the pens.


    8. Remove the needle from the pen and place it in a sharps container. Do not store the pen with the needle attached. This may cause insulin to leak out, and you may not get the correct dose.

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    General Insulin Tips

    • Insulin lowers blood glucose.


    • Insulin can not be taken orally as a pill because stomach enzymes destroy it before it can work.


    • Each kind of insulin has its own characteristic onset, peak and duration.


    • Check with your doctor before changing the amount, type or brand of insulin.


    • Your insulin dosages are based on your blood glucose levels, meal plan and activity. They will probably change over time. This does not mean your diabetes is getting worse!


    • Double check the dose. If you overdraw, start over.


    • Use the insulin by the expiration date on the bottle. An open bottle of insulin can be kept in the refrigerator or at room temperature, but once it is open it is only good for 30 days. Keep unopened vials of insulin in the refrigerator.


    • Ask your diabetes educator to show you ways to get rid of air bubbles.


    • Lantus® (glargine) and Levemir® (detemir) can not be mixed with other insulins.


    • If the needle bends while you draw up the insulin, do not straighten it. Place the bent needle in a sharps container and start over with a new needle.


    • If you notice a bump or bruise at the site of an injection, avoid using that site again until it returns to normal.


    • If you need to use two types of insulin for an injection, refer to “Mixing Insulins” in your insulin start kit or ask to see a diabetes educator.


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    Action and Timing of Different Types of Insulin

    The point at which insulin starts working is called the onset. The time when insulin is working the strongest is called the peak. The duration is how long the insulin works in the body before it is gone. Knowing when insulin is working in your body helps you to reduce your risk for low blood glucose by taking proactive steps (for example, carrying a snack with you when away from home).

    Insulin Type ColorOnset ((time) Peak ((time) Duration(time)
    Rapid Acting: Humalog® (lispro), Novolog® (aspart), Apidra® (glulisine)Clear0 - 15 minutes30 - 90 minutesUp to 5 hours
    Short Acting: Novolin R®Clear30 minutes2 - 5 hoursUp to 8 hours
    Intermediate Acting NPH: Humulin N®, Novolin N®Milky white when mixed (rotate vial to mix)2 - 4 hours6 - 10 hoursUp to 20 hours
    Long Acting: Lantus® (glargine), Levemir® (detemir)Clear1 - 2 hoursNo peakUp to 24 hours
    Premixed - Short and Intermediate Acting: Humulin® 70/30, Novolin® 70/30, Humulin® 50/50Milky white30 minutes - 1 hour2 - 10 hoursUp to 20 hours
    Premixed - Short and Intermediate Acting: Humulin® 70/30, Novolin® 70/30, Humulin® 50/50Milky white30 minutes - 1 hour1 - 6 hours14 hours
    Premixed - Rapid and Intermediate Acting: Humalog-Mix® 75/25, Novolog-Mix® 70/30, Humalog® 50/50Milky white0 - 15 minutes30 minutes - 12 hoursUp to 20 hours


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    Other Injectables

    There are other injectable medicines such as Byetta® (exenatide), Victoza® (liraglutide) and Symlin® (pramlintide) that help lower blood glucose levels. Your health care provider may prescribe one of these depending on your need and the type of diabetes you have.

    "Mimetics" (not insulin) act like gut hormones to slow digestion. Decreases glucose production in liver. Increases mealtime fullness.
    Brand Name (Generic Name)Dose RangeWhen to Take
    Byetta® (exenatide)5 -10 mcg 2 times a day, 60 minutes or less before breakfast and dinner
    Victoza® (liraglutide)0.6 mg daily for one week. If not effective for glycemic control, increase to 1.2 mg for one week. If not effective, increase to 1.8 mgOnce a day with or without food
    Symlin® (pramlintide acetate)15 - 120 mcgBefore meals, up to 3 times a day

    Considerations for Byetta® and Victoza®:
    • Nausea common at first


    • Nausea decreases after meal


    • Do not take if you skip a meal


    • Do not take after a meal (may cause vomiting)


    • Low glucose can occur when taken with medications listed in "Insulin Secretogogues"


    • Exenatide is not recommended for people with severe kidney problems, high triglycerides, or digestion problems
    Considerations for Symlin®:
    • Considerations as above


    • Only used for people on insulin (type 1 and 2)


    • Reduce short-acting, mealtime insulin by 50% when starting pramlintide


    • Pramlintide is not recommended for people with digestion problems



    Produced by the staff and physicians at California Pacific Medical Center in association with the Center for Patient and Community Education. Last updated: 12/11

    Funded by: A generous donation from the Mr. and Mrs. Arthur A. Ciocca Foundation.

    Note: This information is not meant to replace any information or personal medical advice which you get directly from your doctor(s). If you have any questions about this information, such as the risks or benefits of the treatment listed, please ask your doctor(s).

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