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Full Circle Studios, LLC
Script for
“Diabetes Self-Care: An Action Plan to Reduce Complications”
Client: Jeff Ensminger (dba “Propel Health”)
Version 1.0 – Section 5 - Medications
Scene Audio Video
Medications
Background graphic of an oral medication. In this chapter, we’ll look at several types of oral medications used by people with diabetes. We’ll review their effects, including side effects that might be experienced by users. You don’t need to view information about all of the oral medications unless you want to. Instead, you can select the medication that’s of particular interest to you. We’ll also discuss insulin, in its various forms, and methods for Finally, we’ll take a look at some other medications to help control blood glucose. Since new medications and insulin products are being developed all the time, you should visit our web site, www.propelhealth.com, to get There is a quiz for this chapter at the end of the section on “Other Show person selecting “Take Quiz” on DVD medications”. If you are planning to take the quiz, you should view the first two topics from the menu below before viewing “Other Also, there is a glossary of terms used in this DVD. To access this Show Main Menu, selection of “Additional glossary, go to the Main Menu, select “Additional Resources” and then Resources” and highlight “Glossary” Page 1 of 1 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

Oral medications (go to 5B, then sub-menu) 5B - Oral Medications
Video of person injecting medication/insulin; Generally speaking, medications work on three problems of metabolism Insufficient insulin because the pancreas is unable to produce a Insulin resistance, where the peripheral membranes (or “walls”) of cells in the body do not utilize insulin effectively; and A condition called “gluconeogenesis” where the liver is releasing an All of these problems are dangerous if not properly controlled. Let’s take a look at several types of commonly used oral medications. You may select a medication from the following menu in order to learn more about it. Oral medication sub-menu:
Sulfonylurea (e.g., Glucotrol, Amaryl) – go to 5B.2 Meglitinides (e.g., Prandin, Starlix) – go to 5B.3 Biguanides (e.g., Glucophage, Glucovance ???) – go to 5B.4 Thiazolidinedione (e.g., Actos, Avandia) – go to 5B.5 5B.2a VO:
Sulfonylurea is perhaps the oldest type of oral medication. The current form is considered a “second generation” of the medication because it is Either a graphic showing action of medication Page 2 of 2 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

an improved version of the original. It works by stimulating beta cell on beta cell insulin release or text graphic release of insulin. [JEFF: DO YOU NEED TO EXPLAIN “BETA CELL” HERE?] In other words, it doesn’t “make” more insulin, it simply boosts the beta cells’ ability to release insulin. This group of medications includes glyburide (previously marketed under the brand names DiaBeta, Micronase and Glynase) [JEFF: NOT SURE WHAT “PREVIOUSLY” REFERS TO. WHAT IS THIS MEDICATION CURRENTLY SOLD AS?]; glipizide (sold under the brand name Glucotrol), and glimiperide (sold under the brand name Amaryl). 5B.2b VO:
These medications are available in various dosages: Glyburide, or ???, comes in 2.5 and 5 mg doses; the maximum dosage superimpose dosage info Glipizie, or Glucotrol comes in 5 and 10 mg doses; it also comes in an extended release form known as Glucotrol XL Glimiperide, or Amaryl, comes in 1, 2 and 4 mg doses 5B.2c VO:
These medications should be taken 30 minutes before meals. They may be Show person taking a medication; freeze, expected to produce a 60-70 point reduction in glucose levels, depending on your eating and activity regimen. Generally, these medications are effective up to ten years. [JEFF: DO WE WANT TO SAY WHY THEY ARE NO LONGER EFFECTIVE AFTER 10 YEARS?] Possible side effects of sulfonylurea medications include: hypoglycemia; headaches; nausea; diarrhea; and sun sensitivity. Consumption of alcohol while taking this type of medication will increase your risk of hypoglycemia. • Hypoglycemia (increased with alcohol Also, this medication may cause weight gain. Page 3 of 3 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

5B.3a VO:
Meglitinides include Repaglinide (sold under the brand name, Prandin) and Nateglinide (sold under the brand name, Starlix). Like sulfonylurea • Stimulate beta cells to release more medications, meglitinides work by stimulating the beta cells to release more insulin. However, meglitinides have a shorter duration of actions in • Shorter duration than sulfonylurea – the body, reducing the likelihood of hypoglycemia hours after taking the 5B.3b VO:
These medications are available in various dosages: Repagllinide, or Prandin, comes in 0.5, 1 and 2 mg tablets Nateglinide, or Starlix, is available in 60 or 120 mg tablets 5B.3c VO:
Show person taking a medication; freeze, These medications should be taken 15 minutes before eating, but never 5B.3d VO:
Possible side effects of meglitinide medications include: hypoglycemia; headaches; nausea; diarrhea; and sun sensitivity. Consumption of alcohol while taking this type of medication will increase your risk of hypoglycemia. Also, this medication may cause weight gain. 5B.4a VO:
Biguanides include metformin, sold under the brand name of Glucophage, superimpose graphic: which works by suppressing the production of glucose by the liver and Page 4 of 4 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

improving glucose uptake in the peripheral cells. It enables the body to • Improves glucose uptake in peripheral use its natural insulin more effectively. 5B.4b VO:
Glucophage is available in doses of 500, 850 and 1,000 mg. It also comes in an extended release form, called Glucophage XR, and part of Glucovance [JEFF: DO WE NEED TO EXPLAIN GLUCOVANCE?] This medication should be taken with food. 5B.4c VO:
Glucophage may be expected to produce a 60-70 point decrease in glucose levels, depending on your eating and activity habits. This effect should occur within two weeks of starting the medication. It may also • May decrease LDL (“bad” cholesterol) help with weight loss as patients often experience a decrease in hunger. Furthermore, Glucophage may cause a decrease in LDL, or “bad” cholesterol levels. 5B.4d VO:
Possible side effects of Glucophage include: diarrhea and nausea, which are common initially – especially if the initial dose is higher than 500 mg. For this reason, it’s recommended that patients start gradually and work their way up to the recommended dose gradually – over a period of days or weeks. Other side effects include: a metallic taste; flatulence; headaches; abdominal discomfort; lactic acidosis; muscle pain; and 5C - Insulin
Video of person preparing to take insulin Page 5 of 5 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

Insulin has been called “the gold standard” of care for people with diabetes. The amount of insulin you take can be adjusted, based on your blood glucose levels and the amount of carbohydrates you’re eating – unlike oral medications which have a fixed dose and thus provide less flexibility. (continue video of person preparing to take Unless you’re currently using insulin, your perception about it might be out-of-date. There have been many improvements in insulin over the years and it’s significantly better than what your grandparents might have used. For example, insulin pens have eliminated the need to “draw up” insulin from a vial into a syringe; and the needles are very small today. In fact, almost everyone who starts insulin finds it surprisingly easy to adjust Now, let’s look at some of the types of insulin currently in use. Image of packages of Novolog and Humalog; Rapid-acting insulin, such as Novolog and Humalog, has an onset time of about 15 minutes. This means it takes about 15 minutes to reach the blood and start reducing glucose levels. It reaches its peak effect between one and two hours and its duration – or, the total length of time it’s effective – Rapid-acting insulin is used to control glucose levels at meals and/or • Do NOT take if not eating or glucose is when glucose levels are excessively high and need to be reduced quickly. This type of insulin should NOT be taken if a person is not eating and their glucose levels are in control – that is, below 120 mb/dL. Rapid-acting insulin most closely resembles the release of insulin by the pancreas in people without diabetes. Also, it’s the only insulin used by insulin pumps – which we’ll discuss further in a few minutes. Image of package of “N” or “NPH” insulin; Page 6 of 6 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

Another form of insulin is called “Intermediate-acting insulin,” also known as “N” or “NPH” insulin. The onset of intermediate-acting insulin is two-to-four hours. Its peak effect is between four and ten hours, and its duration is twelve-to-twenty hours. The absorption of intermediate insulin into the blood can vary by 30% or more, often causing unexpected high or low glucose levels. Intermediate-acting insulin is considered a “background” or “basal” insulin, meaning it’s effective over a long period • Considered “background” or “basal” of time. Usually, it’s injected two times a day and it often comes pre- mixed with rapid-acting insulin. [JEFF: NEED EXPLANATION OF WHY THESE TWO ARE MIXED TOGETHER. e.g., TO PROVIDE BOTH IMMEDIATE AND LONGER-TERM CONTROL OF GLUCOSE LEVELS THROUGOUT THE DAY] Insulin glargine, also known by its brand name, “Lantus,” is similar to Intermediate-acting insulin in that it has a relatively slow onset – between two and four hours, and a long duration – between twenty and twenty-four hours. However, its considered superior to Intermediate-acting insulin because its absorption rate is less variable. In other words, its effect on blood glucose levels is more predictable than Intermediate-acting insulin. Image of packages of pre-mixed insulin (both Another form of insulin is called “premixed insulin.” It’s also known as “75/25” or “70/30” insulin. In the first type, which is made by Eli Lilly, the “75” denotes that the solution is 75% intermediate-acting insulin and In “70/30” insulin, which is made by NovoNordisk, the “70” denotes that the solution is 70% rapid-acting insulin and 30% is intermediate-acting These premixed forms typically are injected twice daily, at breakfast and dinner. Page 7 of 7 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

It’s important to know that the best insulin regimen – that is the schedule for using insulin – varies from person to person, depending on one’s lifestyle, ability to administer insulin, and their level of glucose control. Show younger person running (or doing other For example, four injections a day is probably not suitable for an elderly person who lives alone. Whereas, two injections a day may not be suitable for a physically active individual who wants tight glucose control and less hypoglycemic reactions. Show person drawing up insulin into syringe Although many people use a syringe to inject insulin, this requires a great deal of care in making sure the correct dose is drawn up into the syringe. Show person talking to pharmacist or diabetes Failure to do this carefully can lead to injecting too much or too little insulin. You should ask your diabetes educator, nurse or pharmacist to explain the correct procedures for injecting the right dose of insulin. Insulin pens have a pre-filled cartridge of insulin. This avoids the need to Show a different person preparing to use “draw up” insulin from a vial into a syringe. People using the pen need to “screw” on a pen needle and dial the correct dose. All types of insulin can be delivered by a pen. Another device for administering insulin is the insulin pump. Unlike injections, the pump allows users to speed up, slow down, or stop insulin delivery with the touch of a few buttons. People using the pump have one injection of a “port” – usually every 2-3 days. Pumps only use rapid acting insulin, which is pumped into the body every few minutes. Pumps calculate the amount of insulin that’s appropriate for each individual and administer the right amount at the right time to maintain control of blood Pumps have proven to reduce hypoglycemic reactions significantly, although users need to be properly trained and test their glucose levels 4-6 Page 8 of 8 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

times a day. Insulin pumps have improved the quality of life of thousands Pump manufacturers include Roche Diagnostics, Medtronic/Minimed and Smith Medical. The cost of a pump is approximately $5,000 and the tubing and ports need to be changed every 2-3 days. These expenses are covered by most insurance carriers. 5C.10 VO:
There are two medications that can help with glucose control. The first is Byetta. This injectable medication is taken along with insulin and it helps improve glucose control and promotes weight loss. Byetta is injected with an insulin pen and should be taken within one hour of meals. Patients should start with a 5 mcg dose and increase to 10 mcg 5C.11 VO:
Byetta has three effects that help with glucose control. Its primary effect is to replace first phase insulin response that becomes absent in Type 2 diabetics. [JEFF: DO WE NEED TO EXPLAIN “FIRST PHASE INSULIN RESPONSE”?] 5C.12 VO:
The second effect of Byetta is that it suppresses the secretion of glucagons Suppresses secretion of glucagons during during times of hyperglycemia, which, in turn, reduces the secretion of glucose by the liver. [JEFF: DO WE NEED TO EXPLAIN “GLUCAGONS” HERE?] 5C.13 VO:
The third effect of Byetta is that it slows gastric emptying [JEFF: CAN WE USE ANY OTHER TERM HERE? Eg “SLOWS DIGESTION” or will people understand what this means?] which also improves glucose control and causes people to eat less because they feel “full” longer after Page 9 of 9 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

5C.14 VO:
Byetta does increase the risk of hypoglycemia, so sulfonylureas and meglitinides may need to be reduced [JEFF: WILL PEOPLE KNOW Contraceptives & antibiotics should be WHAT THIS MEANS? SHOULD WE USE BRAND NAMES?] Also, contraceptives and antibiotics should be taken at least one hour prior to Byetta injection. 5C.15 VO:
Another medication is Symlin, which is for type 1 or type 2 diabetes who inject insulin for glucose control. It is a synthetic form of the hormone amylin, which is released along with insulin by normal functioning beta cells in a person without diabetes. However, in people with diabetes whose beta cells are either damaged or destroyed, the body doesn’t release insulin or amylin in proper amounts to provide glucose control. 5C.16 VO:
Symlin has proven to reduce the amount of meal time insulin required to control postprandial [JEFF: ANY OTHER WORD WE CAN USE HERE? DON’T KNOW IF MOST PEOPLE WOULD KNOW WHAT THIS MEANS] glucose levels, reduce daily glucose fluctuations by suppressing excess glucagons secretion, and help people lose weight when compared to people injecting insulin alone. 5C.17 VO:
Symlin should be injected at meals at the same time as rapid acting insulin and should NOT be mixed with insulin. Symlin is available in 5 ml. vials and injected by syringe. It’s not available in an insulin pen device. For people with type 2 diabetes, utilizing insulin for glucose control, insulin should be reduced by 50% at meals and Symlin should be initiated with a dose of 60 ug. [JEFF: WHAT IS “ug” ? DO WE NEED TO EXPLAIN THIS?] The dose of Symlin should be increased to 120 ug after 3 to 7 days if there are no signs or symptoms of nausea. After Page 10 of 10 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health Full Circle Studios, LLC
Project: Diabetes Self-care
Version 1.0 - Section 5 (Medications)

achieving this dose level, patients should increase insulin for postprandial glucose control. 5C.18 VO:
For people with type 1 diabetes, meal time insulin should be reduced by 50% and Symlin should be initiated at 15 ug, and gradually increased in 15 ug increments to a maintenance dose of 30 to 60 ug. Once this level is achieved, insulin levels should be adjusted to maintain proper glucose 5C.19 VO:
Much like insulin, Symlin increases the risk for severe hypoglycemia up to three hours after injection, so it’s important to monitor glucose levels frequently. Nausea is also a possible side effect. Symlin should be stored in the refrigerator and protected from light. Once opened, it can be kept for up to 28 days. Show package being put into refrigerator This concludes this chapter on medications. Now, you may choose to take a test on the material covered in this chapter, or simply return to the menu Page 11 of 11 Updated 3/27/2007 1:17 PM Copyright 2005 Propel Health

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