Acarbose


Article Author:
Lindsey McIver


Article Editor:
Jayson Tripp


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


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Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
10/8/2019 6:28:29 PM

Indications

Acarbose is FDA approved for the treatment of adults with type 2 diabetes mellitus as an adjunct to diet only or diet and exercise, depending on the patient's health status.

Based on the combined data of six placebo-controlled trials in patients with type 2 diabetes mellitus using acarbose as monotherapy, researchers noted the following changes from baseline glycosylated hemoglobin (hemoglobin A1c) by dose: 

  • Acarbose, 25 mg three times daily, decrease by 0.44
  • Acarbose, 50 mg three times daily, decrease  by 0.77
  • Acarbose, 100 mg three times daily, decrease by 0.74
  • Acarbose, 200 mg three times daily, decrease by 0.86
  • Acarbose, 300 mg three times daily, decrease by 1.00

Although the acarbose 300 mg three times daily regimen is superior to lower doses at lowering hemoglobin A1c, the approved maximum daily dose of acarbose is 100 mg three times daily. There is no statistically significant difference in hemoglobin A1c lowering between the 50 mg three times daily regimen, 100 mg three times daily regimen, and the 200 mg three times daily regimen.

Acarbose is not FDA approved for the treatment of type 1 diabetes mellitus; however, studies have evaluated the safety and efficacy in this patient population. In a study of 121 patients with type 1 diabetes mellitus, acarbose 50 mg three times daily for two weeks, followed by 100 mg three times daily, was found to reduce 2-hour postprandial glucose significantly. There were no differences between the placebo group and the acarbose group in hemoglobin A1c lowering or episodes of hypoglycemia.[1] In two subsequent, single-center, placebo-controlled studies, 40 patients with type 1 diabetes mellitus were given metformin for six months after acarbose replaced metformin. Acarbose was shown to significantly decrease the 2-hour postprandial blood glucose level when compared to baseline. When compared to metformin therapy, the acarbose therapy group was found to have a statistically significant decrease in low-density lipoprotein (calculated), triglycerides, and total cholesterol. Acarbose use also led to a statistically significant decrease in regular insulin use.[2]

Acarbose is not FDA approved for the treatment of prediabetes. However, it has undergone evaluation as a potential pharmacologic option for preventing the progression from prediabetes to type 2 diabetes mellitus. In a study of patients with impaired glucose tolerance tests, participants were randomized to acarbose 100 mg three times daily or placebo three times daily. Thirty-two percent of the acarbose group developed type 2 diabetes mellitus compared to 42% in the placebo group, resulting in a statistically significant hazard ratio of 0.75.[3]

The effect of acarbose on weight loss has also been a target of research. In an analysis of post-marketing data of 67682 patients, acarbose was found to decrease body weight significantly, independent of baseline body weight. It also was found to significantly decrease fasting plasma glucose, postprandial glucose, hemoglobin A1c, and postprandial glucose excursion.[4]

Mechanism of Action

Acarbose is a complex oligosaccharide that acts as a competitive, reversible inhibitor of pancreatic alpha-amylase and membrane-bound intestinal alpha-glucoside hydrolase. Pancreatic alpha-amylase hydrolyzes complex carbohydrates to oligosaccharides in the small intestine. Intestinal alpha-glucosidase hydrolase breaks down oligosaccharides, trisaccharides, and disaccharides (sucrose, maltose) to monosaccharides (glucose, fructose) in the brush border of the small intestine. By delaying the digestion of carbohydrates, acarbose slows glucose absorption, resulting in a reduction of postprandial glucose.

Pharmacokinetics

Absorption

Acarbose acts locally in the gastrointestinal (GI) tract with low systemic bioavailability (less than 2% gets absorbed as the active drug, and 35% as metabolites).

Metabolized

Acarbose is metabolized in the GI tract by intestinal bacteria and digestive enzymes.

Excretion

The kidneys excrete the absorbed drug, and 51% of an oral dose gets excreted in feces.

Administration

Acarbose is available as a 25 mg, 50 mg, or 100 mg oral tablet. It should be administered orally three times daily with the first bite of each meal. Initial dosing is 25 mg orally three times daily; however, starting with once-daily dosing may limit GI adverse effects. From 25 mg by mouth three times daily, the dose can be titrated every 4 to 8 weeks to reach desired glycemic control while limiting GI adverse effects. The maximum daily dose is 100 mg three times daily.

  • If the patient weighs less than 60 kg, the dose should not exceed 50 mg three times daily.
  • Use has not had research performed in patients with renal dysfunction (serum creatinine greater than 2.0 mg/dL).
  • Safety and efficacy have not undergone evaluation in pediatric patients.
  • The safety of acarbose has not been established in pregnant patients.
  • Acarbose should not be used in nursing mothers.

Drug-Drug Interactions

  • Acarbose may decrease the bioavailability of digoxin and valproic acid.
  • Acarbose may increase hypoglycemic risk when combined with other anti-diabetic agents that cause hypoglycemia.
  • Digestive enzymes, including amylase, lipase, and protease, may decrease the effectiveness of acarbose.
  • Therapy requires monitoring with other agents that affect blood glucose levels.

Adverse Effects

The most common adverse effects are GI symptoms, including flatulence, diarrhea, and abdominal pain. A high carbohydrate diet may worsen the GI adverse effects. GI symptoms tend to become reduced throughout treatment.

Elevated serum transaminases may occur during acarbose therapy. Elevations usually are asymptomatic and reversible once stopping drug therapy.

Hypoglycemia should not occur with acarbose monotherapy. However, the therapy can increase the risk of hypoglycemia when used with antidiabetic agents that cause hypoglycemia such as sulfonylureas or insulins.

Post-marketing reports include cases where there were rare occurrences of pneumatosis cystoides intestinalis with alpha-glucosidase inhibitor use.

Contraindications

Acarbose use is contraindicated in patients with known hypersensitivity, diabetic ketoacidosis, liver cirrhosis, inflammatory bowel disease, or colonic ulceration. It also is contraindicated in patients with intestinal obstruction or those predisposed to intestinal obstruction; patients with chronic intestinal disease, including those who have issues with digestion or absorption; or conditions that will be worsened by the increased gas formation in the intestine.

Monitoring

One- to 2-hour postprandial blood glucose levels and glycosylated hemoglobin should be monitored to assess efficacy. Serum transaminase levels should be checked every three months for the first year of therapy. The clinician should decrease the dose or discontinue therapy if levels become elevated during treatment.

Toxicity

Overdose with acarbose will not cause hypoglycemia but may increase GI adverse effects. If an overdose occurs, patients should not have food or beverages that contain carbohydrates for 4 to 6 hours.

If a patient experiences hypoglycemia while taking acarbose in combination with other anti-diabetic medications, the patient should be counseled to use glucose (gel, tablets, etc.) as acarbose will prevent the breakdown of sucrose (table sugar) and delay glucose absorption, therefore, failing to correct hypoglycemia quickly. Severe hypoglycemia may require intravenous glucose or intramuscular glucagon administration.

Enhancing Healthcare Team Outcomes

Acarbose is a commonly used medication for the management of type 2 diabetes. While the drug is useful, it is not a great agent when used as monotherapy. Because the drug works in the gastrointestinal system, its most common adverse effects are gastrointestinal upset/bloating. Hence, the nurse practitioner, a pharmacist, and the primary care provider must educate the patient on how to use the drug. Further, patients should receive counsel to avoid cola beverages, as the abdominal symptoms may worsen. While hypoglycemia is extremely rare with this agent, if it occurs, one should consider other antidiabetic drugs as the cause. The patient should be treated for hypoglycemia and then counseled on how to prevent further episodes of low sugar. Only through patient education can the side effects be limited, and as with any medication, acarbose management is best by an interprofessional healthcare team across various disciplines. [Level V]


  • Image 6284 Not availableImage 6284 Not available
    Contributes by Acarbose Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc.; 2011.
Attributed To: Contributes by Acarbose Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc.; 2011.

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Acarbose - Questions

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A 45-year-old female with a history of seizures that was well controlled with valproic acid presents to the office. The patient developed type 2 diabetes mellitus after being seizure-free with no changes occurring in her valproic acid over that time period. The practitioner started an oral medication to help control postprandial sugars levels. The patient started to experience severe flatulence and diarrhea. Three months after starting the medication, she was found to have elevated serum transaminases and had 2 seizures during that time period after being seizure-free for the past 5 years. What is the likely mechanism of action of the drug prescribed by the practitioner?



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The enzyme alpha-glucosidase is inhibited by which antidiabetic medication?



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A female who is obese is found to have persistent hyperglycemia and is diagnosed with type 2 diabetes mellitus. She is started on acarbose. What is the mechanism of action of this drug?



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Which of the following antidiabetic medications inhibit enzymes of digestion in the intestine?



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Which "starch blocker" medication can decrease postprandial hyperglycemia?



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What is the mechanism of action of acarbose?



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Which of the following drugs can be used to decrease postprandial increases in plasma glucose?



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A 44-year-old male patient with type 2 diabetes mellitus is taking an oral medication that is routinely administered with the first bite of a meal. The medication is effective in lowering postprandial glucose levels. Overdosing of the medication will not cause hypoglycemia. The medication is contraindicated in patients with liver cirrhosis, inflammatory bowel disease, and intestinal obstruction. What is the mechanism of action of the medication the patient is utilizing?



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A 33-year-old male with a body mass index of 32 was newly diagnosed with type 2 diabetes mellitus. He was subsequently started on a medication that does not cause hypoglycemia when used in monotherapy and decreases postprandial glucose levels. The medication works in the area of the brush border of the small intestines. Digestive enzymes, including amylase, lipase, and protease, may decrease the effectiveness of the medication. The medication works by reducing the rate of digestion of which of the following?



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Which of the following is not an important counseling point for patients who are being prescribed acarbose monotherapy?



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A patient is given a prescription for what his provider called a "starch blocker." He was warned that the medication might cause increased flatulence, with stomach cramping, and "belly noise." Which of the following is most likely the "gas" drug?



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Which of the following medications is an alpha-glucosidase inhibitor used in the management of diabetes mellitus?



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Acarbose - References

References

Efficacy and safety of acarbose in the treatment of Type 1 diabetes mellitus: a placebo-controlled, double-blind, multicentre study., Riccardi G,Giacco R,Parillo M,Turco S,Rivellese AA,Ventura MR,Contadini S,Marra G,Monteduro M,Santeusanio F,Brunetti P,Librenti MC,Pontiroli AE,Vedani P,Pozza G,Bergamini L,Bianchi C,, Diabetic medicine : a journal of the British Diabetic Association, 1999 Mar     [PubMed]
Comparison of adjunctive therapy with metformin and acarbose in patients with Type-1 diabetes mellitus., Ziaee A,Esmailzadehha N,Honardoost M,, Pakistan journal of medical sciences, 2017 May-Jun     [PubMed]
Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial., Chiasson JL,Josse RG,Gomis R,Hanefeld M,Karasik A,Laakso M,, Lancet (London, England), 2002 Jun 15     [PubMed]
Acarbose reduces body weight irrespective of glycemic control in patients with diabetes: results of a worldwide, non-interventional, observational study data pool., Schnell O,Weng J,Sheu WH,Watada H,Kalra S,Soegondo S,Yamamoto N,Rathod R,Zhang C,Grzeszczak W,, Journal of diabetes and its complications, 2016 May-Jun     [PubMed]

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