As a person with prediabetes, I have come to appreciate metformin extended release (major benefit of less diarrhea with extended release) although I must admit they are big pills. Good news! The only FDA- approved liquid formulation of metformin extended release (Riomet ER) is now available. The liquid formulation of metformin immediate release (more diarrhea with immediate release) has been available for a good while. Liquid formulation option for the big “horse” pill.
BJ, a 68-year-old male, has been living with diabetes for over 20 years. Recently, BJ was caught off guard when he found out he had developed heart failure and established heart disease. He pondered, how could this have happened? He had been working hard to manage his diabetes and make healthier choices. BJ is not alone out there.
Did you know that diabetes increases
risk of developing heart disease? Heart disease is commonly caused by the
buildup of cholesterol in the blood vessels that supply oxygen and nutrition to
the heart. These cholesterol plaques can break apart or rupture, which the body
will then try to repair the plaque by sending platelets to seal it up. However,
the artery is small, so the platelets could possibly block the flow of blood
and not allow for oxygen delivery and then a heart attack may develop. It could
also result in not enough blood to the brain and cause a stroke, or not enough
blood to the feet, hands, or arms causing peripheral vascular disease. High
blood sugar from diabetes can damage your blood vessels and the nerves that
control your heart and blood vessels over time and the longer you have
diabetes, the higher the chances for you to develop heart disease.
So what prevention steps can be
taken? Remember, the major contributors to heart disease (heart attack and
stroke) are high blood pressure, high cholesterol levels (particularly low-density
lipoprotein (LDL) (or as I call it, lousy cholesterol), and blood clots. The following
are recommended goals and medications for each of these contributors:
Blood pressure management
Goal BP <140/90 mmHg (ADA Guidelines)
Common medications classes for that you may be
on for high blood pressure: (don’t let the long names overwhelm you)
Angiotensin Converting Enzyme Inhibitor
(ACEI):
i.e. Lisinopril (Zestril) or Enalapril (Vasotec)
Angiotensin Receptor Blocker (ARB):
i.e. Valsartan (Diovan) or Losartan (Cozaar)
Thiazide Diuretic:
i.e. Hydrochlorothiazide (Microzide) or Chlorothiazide
(Diuril)
Calcium Channel Blockers:
i.e. Amlodipine (Norvasc) or Nifedipine
(Procardia)
Controlling Bad Cholesterol, Low Density
Lipoprotein (LDL or lousy cholesterol)
Goal LDL: if have established cardiovascular
(heart) disease, goal LDL < 70 mg/dL
Primary medication class for you treating
elevated LDL:
Statin:
Atorvastatin (Lipitor)
These
drugs lower bad cholesterol levels by blocking an enzyme that the liver uses to
make cholesterol
Preventing Blood Clots
Blood clots can form and break off and travel
through the body and cause blockage of blood vessels
If a blockage happens in a blood vessel to the
brain, it can result in a stroke
Medication to prevent blood clots:
Blood
thinner: low-dose Aspirin (81mg)
I encourage you to talk with your health care professional
if you have questions.
Diabetes medications, in particular some sodium glucose
co-transporter 2 (SGLT-2 inhibitors and glucagon-like peptide 1 (GLP-1)
agonists, have shown to have particular benefits in prevention of heart disease
complications. Below you will find a table with the agents/drugs in class and
their indication unique for heart disease.
Drug name
Benefits
Heart Failure (HF) (lower
hospitalization risk for heart failure)
Major adverse cardiovascular event (MACE) reduction (Ex. Heart attack and stroke)
Along with treatment, it is always important to implement non-drug treatment such as your diet, physical activity, and smoking cessation.
For your diet, multiple options for healthy
eating plans are described below and are proven to work for persons with
diabetes. Food is medicine, so what and
how much we eat really matters.
Dietary Approach to Stop Hypertension (DASH)
diet:
Eating plan rich in fruits and vegetables,
low-fat and nonfat dairy, whole grains, along with nuts, beans, and seeds
Also includes some
Cut back on foods high in saturated fat, such as
fatty meats, full-fat dairy foods and tropical oils, as well as sugar-sweetened
beverages and sweets
Limiting salt to less than 2,300 mg per day or
less than 1,500 mg per day
Carbohydrate counting
Working with diabetes care and education specialist
(formerly diabetes educator) learn how to count carbohydrates
Typically recommend 30 – 45 grams of carbohydrates
per meal, and 15 grams of carbohydrates per snack
Healthy Eating Behaviors
Learning portion control
Plate Method: ½ plate nonstarchy veggies, ¼ plate
protein, ¼ plate of starch (carbohydrate), diary product (i.e. milk or yogurt)
and fruit
Mediterranean diet
High in vegetables, fruits, whole grains, beans,
nuts, seeds, and olive oil
Plant based, not meat based
Main components:
Daily intake of vegetables, fruits, whole grains
and healthy fats
Weekly intake of fish, poultry, beans and eggs
Moderate portions of dairy products
Limited intake of red met
Along with diet, moving your body
each day is key for keeping the heart healthy.
The 2020 ADA Standards of Care Guidelines recommends at least 150
minutes a week, that’s less than 22 minutes each day, of moderate-intensity
physical activity such as brisk walking. This will not only help you manage
your weight, but also help lower your blood sugars, blood pressure, and
cholesterol which will essentially help reduce your risk for heart disease and
many other potential complications.
Last but not least, it is important
to stop smoking. Smoking can lead to so many illnesses including lung cancer,
chronic pulmonary disease (COPD) or progressive disease of the lungs, and
atherosclerotic cardiovascular disease or Heart disease.
Lifestyle modifications along with
your treatment therapy will help reduce your risk of heart disease and also
improve your quality of life so you can live out the best possible life!
Back to BJ, he recently met with this primary care provider who placed him on empagliflozin (Jardiance) 25 mg once daily and semaglutide (Ozempic) 0.5 mg once weekly because he has diabetes, heart failure and heart disease. He is relieved that his diabetes medications will help both manage his diabetes and protect his heart.
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Dulaglutide, Trulicity, has received a new FDA indication for prevention of primary (person has no established heart disease, or history of heart attack or stroke) AND secondary (person has established heart disease, or history of heart attack or stroke) reduction of major adverse cardiovascular (heart) events (i.e. heart attack or stroke) in adults with type 2 diabetes. Adults with type 2 diabetes have an elevated risk for heart attacks and strokes so proactive prevention is vital. What makes this new indication particularly important is that it is for prevention in person with or without established heart disease.
Unfortunately, we have two recalls this week. FDA has issues a class I recall (most serious) for certain Medtronic MiniMed 600 series (please click on link below for specifics) due to incorrect insulin dosing which has caused 2,175 injuries and one death.
Secondly, Eisai manufacturer of weight loss medication, lorcaserin (Belviq), has agreed to voluntarily withdrawal lorcaserin from the market due to concerns of cancer risk.
As a person with prediabetes who takes metformin, I am excited to share that the FDA recommends no recall on metformin. This is a follow up from Tuesday’s Daily Piece regarding the testing of metformin for NDMA. Please share this good news.
If you recall in 2019, several generic medications were pulled from the market due to having unacceptable levels of N-Nitrosodimethylamine (NDMA) impurity as NDMA increases risk of cancer. Concerns regarding the level of NDMA in generic metformin surfaced in late 2019. Good news came out earlier this week that the FDA found no tested samples of generic metformin contained unacceptable levels of NDMA important. Please click below to found additional details regarding the tested samples of metformin.
CVS Health announced a new program, RxZERO, which sounds amazing. It promises to eliminate out of pocket expenses for diabetes medications. Wow!!! Oh exciting until you read closely that it requires employees with diabetes to use only approved generic diabetes medications – no branded medications. So this “amazing” program does not eliminate copays for SGLT-2 inhibitors, GLP-1 agonists, most DPP-IV inhibitors, branded insulin.
I don’t know about you but I like the idea of 3 meds in 1 pill. Well we now have a new 3 in 1 diabetes combination medication on the market. Trijardy XR contains empagliflozin (Jardiance) (SGLT2 inhibitor with additional indication to reduce risk of cardiovascular (heart related) death in adults with type 2 diabetes and established cardiovascular disease), linagliptin (Tradjenta) (DPP-IV inhibitor) and metformin XR (backbone of treatment for type 2 diabetes).
I am thrilled to share the exciting new name of diabetes care and education specialists for the specialty formerly known as diabetes educators. This new title for the specialty more accurately captures the role of the specialty. Certified diabetes educators are now certified diabetes care and education specialists. As a diabetes care and education specialists myself, I do more than simply educate. American Association of Diabetes Educators (AADE) is now the Association of Diabetes Care and Education Specialist (ADCES). Having served on the Board of Directors of AADE during the process of changing name of specialty and association, I confidentiality say that the research backs the name change as well as input from key stakeholders. For more information on the timely and essential name change, please click below.
In a recent study published in Annals of Internal Medicine, sodium glucose cotransporter-2 (SGLT2) inhibitors were found to have a reduced risk for gout as compared to glucagon like peptide 1 (GLP-1) agonist. In this study patient taking SGLT2 inhibitor had 36% reduced risk of developing gout. The study design, population-based cohort study, is not the most robust study design as well as gout risk factors were not accessed in the study. While this is promising, more studies are needed.
