Classes of insulin and different treatment regimens are discussed in the third episode of a 3-part series on diabetes. This episode also marks the conclusion of our coverage of the "Big Three" of modern medicine (hypertension, dyslipidemia, and diabetes), and with it, we make an official announcement of the launch of the Family Pharm Podcast to the world (aka Facebook)!

 




Class
Drug
Onset
Peak
Duration


Very Rapid-acting Insulin Analogues
insulin aspart
(NovoRapid)
10–15 min
60–90 min
4–5 h



insulin glulisine
(Apidra)






insulin lispro
(Humalog)





Rapid-acting Insulin
insulin regular
(Humulin R, Novolin ge Toronto)
30–60 min
2–4 h
5–8 h


Intermediate-acting Insulin
insulin NPH
(Humulin N, Novolin ge NPH)
1–2 h
5–8 h
14–18 h


Long-acting Insulin Analogues
insulin detemir
(Levemir)
1.5 h
Flat, no discernible peak
24 h



insulin glargine
(Lantus)





Mixed (regular/NPH) Human Insulin
insulin regular/insulin NPH
Humulin 30/70,
Novolin ge 30/70, 40/60, 50/50
Combination of individual components




Mixed Insulin Analogues
insulin lispro/lispro protamine
Humalog Mix25, Humalog Mix50
10–15 min
Not available
Not available


Mixed Insulin Analogues
insulin aspart/aspart protamine
NovoMix 30
10–15 min
60–90 min
15–18 h



Classes of insulin preparations. Adapted from Therapeutic Choices 6th edition.


CDA guideline on insulin for Type 1 diabetes, including description of basal-bolus regimen by carb counting:

	http://guidelines.diabetes.ca/Browse/Chapter12

Examples of insulin regimens from CDA:

	http://guidelines.diabetes.ca/Browse/Appendices/Appendix3

Self monitoring:

	http://guidelines.diabetes.ca/executivesummary/ch9

Diabetes 3: Insulin and Official Launch

priority topics for family medicine and community pharmacy

Science & Medicine

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Medicine

Education

Training

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Educational Technology

Management of Onychomycosis in Canada in 2014 http://www.ncbi.nlm.nih.gov/pubmed/25775640



Drug name:
Brand:
SA
SA Criteria
SA Approval period
Direction
SE
Monitoring


Ciclopirox 8%
Penlac (nail lacquer)
No
Not covered
N/A
Nail lacquer: Apply bid to adjacent skin and affected nails daily. Remove with alcohol every 7 days (treat 4 weeks)
dermatitis, dry skin, local burning sensation



Efinaconazole
Jublia (nail lacquer)
Not covered
Not covered
N/A
Apply to affected toenails once daily for 48 weeks
Ingorwn nail (2%), dermatitis



Terbinafine tablets
Lamisil tablets
Yes
Severe onychomycosis
PLUS
functional disability
PLUS
positive KOH or dermatophyte culture of nail from a licensed lab.
First approval: Three months
Renewals: If required, up to three months.
250mg once daily for 6 weeks (fingernail); 250mg once daily for 12 weeks (toenails)
Headache (13%), diarrhea (6%), nausea, liver enzyme disorder (3%)
Monitor AST/ALT prior to initiation, repeat if used >6 weeks


Itraconazole
Sporanox
Yes
1. Immunocompromised pts/ Or 2. Pulse treatment for severe onychomycosis with functional disability
PLUS
confirmed lab results for candida or dermatophyte infection.
1. Immunocompromised pts approval is indefinite 2. 3 months approval for 2nd group of pts (No need for SA approval if prescribed by HIV/AIDS Dr)
Fingernail involvement: 200mg capsule twice daily for 1 week. repeat 1 week course after 3 week off time Toenails due to Trichophyton rubrum or T mentagrophytes: 200mg once daily for 12 consecutive weeks With or without fingernaikl involvement: 200mg once daily for 12 consecutive weeks Canadian labelling "Pulse dosing": 200mg twice daily for 1 week, then repeat 1 week course twice with 3 week off time between each course
Diarrhea, nausea, headache, skin rash
Liver function in patients with pre-existing hepatic dysfunction, and in all patients being treated for longer than 1 month


fluconazole
Diflucan
Yes
1. Immunocompromised patients.
OR2. Exceptions on an individual basis for fungal infections resistant to first-line medications.
1 day to indefinite (no need for HIV and AIDS Dr to apply for SA)

Onychomycosis

We are back! (Or your money back!)

In this episode, Billy and Tina discuss the PharmaCare coverage status of different classes of diabetes medications.

Sources:

BC PharmaCare Formulary: https://pcbl.hlth.gov.bc.ca/pharmacare/benefitslookup/

BC PharmaCare Special Authority: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority

CDA Formulary Listings for Diabetes Medications in Canada by provinces and territories (Jan 2016): http://www.diabetes.ca/getmedia/c87009a8-29b6-4061-a52a-963d0b077e47/pt-formulary-listing-jan-18-2016.pdf.aspx
*In case the link doesn't work: pt-formulary-listing-jan-18-2016
      


Class
drugs
Other therapeutic considerations
coverage
SA criteria


Biguanide
metformin

covered



Alpha-glucosidase inhibitor (acarbose)
acarbose
Improved postprandial control, GI side-effects
delisted



Incretin agent: DPP-4 Inhibitors
linagliptin (Trajenta)

SA
same as onglyza



sitagliptin (Januvia)

delisted




saxagliptin (Onglyza)

SA
As part of a combination treatment for type 2 diabetes mellitus, 1) When insulin NPH is not an option
AND
2) After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea.


Incretin agent: GLP-1 receptor agonists
liraglutide (Victoza)
GI side-effects
not listed



Insulin
rapid acting (Humalog, novorapid, apidra)
No dose ceiling, flexible regiments
partial coverage




short acting (Humulin R, Novolin Toronto)

covered




NPH

covered




Premixed (Humulin 30/70, Novolin 30/70, 40/60, 50/50)

covered




Premixed (Humalog mix 25, mix 50, Novomix 30)

partial coverage




glargine (Lantus)

SA
A) Type 1 DM or B) Type 2 DM > 17 years old, and 1) requiring insulin and is currently taking insulin NPH and/or pre-mix insulin daily at optimal dosing
AND
2) Has experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management
OR
3) Has experienced or continues to experience severe, systemic or local allergic reaction to existing insulin treatment.



detemir (Levemir)

SA
same as Lantus



new glargine (Toujeo)

not listed



Insulin secretagogue: Meglitinide
repaglinide (gluconorm)
Less hypoglycemia in context of missed meals but usually requires TID to QID dosing
not listed



Insulin secretagogue: Sulfonylurea
glyburide
Gliclazide and glimepiride associated with less hypoglycemia than glyburide
covered




gliclazide

SA (listed everywhere else in Canada)
Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses.


SGLT2 inhibitors
canagliflozin (Invokana)
UTI, genital infections, hypotension, hyperlipidemia, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia)
1 year manufacturer coverage with special plan




dapagliflozin (Forxiga)

1 year manufacturer coverage with special plan




empagliflozin (Jardiance)

not listed



TZD
rosiglitazone
CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect
delisted




pioglitazone

SA
same as onglyza


Weight loss agent (orlistat)
orlistat
GI side effects
not listed



Combination Drugs
sitagliptin and metformin (Janumet)

delisted




linagliptin and metformin (Jentadueto)

SA
same as onglyza

Diabetes Medications and BC Coverage Information

This is planned to be an 8-part series highlighting the take-home points I picked up during the St. Paul's Hospital CME Conference 2014.

Pearls from Part 1 "Internal Medicine":

Alcoholism - Dr. Paul Farnan

	Screen alcohol use disorders routinely to catch those of whom do not appear to have a significant social or occupational impairment.
	Use assertive statements to convey the concern regarding someone's alcohol use.
	Peer support is strongly recommended. Patients should try multiple meetings at different groups before concluding that they are not helpful, as the groups vary in their structure and member characteristics.
	Medical treatments may be considered in select patients: naltrexone, acamprosate, disulfiram.

Gout - Dr. Hyon Choi

	Screen for HLA-B*5801 in Asians (esp. Chinese, Thai, and Korean patients) before starting alopurinol.
	Look for concurrent metabolic disorders.
	"Medication in the pocket" strategy for acute flares: colchicine 1.2mg po x1 then 0.6mg po in 1 hour.
	Use losartan or CCB for concurrent hypertension.
	Low-carb diet and avoid foods with highest purine content.

Cellulitis - Dr. Val Montessori

	Non-purulent cellulitis, most likely caused by Group A Strep, treat with cephalexin (Keflex) 500mg po QID
	Purulent cellulitis, most likely Staph Aureus but still possibly GAS, treat with Septra DS PO BID, and cover GAS with Keflex.
	Complicated wounds, consult ID.

HCV - Dr. Edward Tam

	New therapy more tolerable and has a 95% cure rate, but also exceedingly expensive.
	Refer all HCV RNA positive patients to hepatologists for assessment of treatment.

This Changed My Practice - Dr. Steve Wong

	http://thischangedmypractice.com/

OSA - Dr. Pearce Wilcox

	Co-morbidities with metabolic syndrome -> screen for metabolic syndromes in patients with OSA, and vice versa

What I learned from St Paul’s CME 2014 Part 1

After a 6-month hiatus, Tina - now a newly-hatched PHARMACIST! - and Billy teamed up to relaunch this pet project with a plan to make it more interactive and less sleep-inducing. Did it work with this unscripted episode?

Family Pharm Podcast – RELAUNCHED!

Tina concentrates on the details of ADHD medications and invites your attention to the following:

Non-pharmacological therapy

	behavioural therapy

Stimulants

	methylphenidate
	amphetamines

Non-stimulants

	atomoxetine
	clonidine
	other antidepressants and antipsychotics (to be covered in future episodes)

Diabetes 3: Insulin and Official Launch

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