Medications for Patients with Type 2 Diabetes
Diabetes (a disease in which blood sugar is high) is a chronic, lifelong condition. Broadly speaking, diabetes can be divided into two types. Type 1 diabetes occurs when the insulin producing cells in the pancreas are destroyed by the immune system (autoimmune) by mistake. Type 2 diabetes occurs in people who are generally overweight or inactive and have genetic predisposition to develop diabetes. Insulin is a hormone made by the pancreas to help our body utilize sugar (glucose). Patient with type 2 diabetes are insulin resistant, i.e. their pancreas makes insulin, but their cells, tissues & organs (liver, muscles etc) do not respond to it. This “resistance” requires their body to produce more insulin to control blood glucose levels. Over time, the amount of insulin left in the pancreas is depleted and then blood glucose may become more difficult to control. Often several medicines and ultimately insulin injections are needed to keep blood sugars under control, especially after meals. Early treatment and aggressive weight loss can help prevent this downhill course in most individuals.
Depending on the stage and severity of diabetes, your doctor will recommend a treatment plan to keep you healthy and reduce the risk of diabetes related complications. Balanced and healthy diet is very important and lower intake of high fat or high “carb” food is recommended.
If lifestyle changes, such as diet & exercise are not sufficient in improving blood gucose control, your health care provider may recommend medication(s) to help control diabetes. Medications for type 2 diabetes work through different mechanisms to “undo” the underlying problems at various levels & in different organs.
- Metformin (Biguanides):
This is the first medicine used in most cases and works on the liver to reduce sugar levels. It may cause some weight loss but may also cause stomach upset in some. Therefore, your doctor may start metformin once daily (usually after supper) & gradually increase the dose if necessary. It should not be taken if kidney function is compromised and should be withheld for 48 hours after surgeries or CT scans.
- SGLT-2 Inhibitors:
This class of medications (e.g. Invokana®, Farxiga®, Jardiance®, Steglatro®) work in the Kidneys and help excrete some sugar through the urine. They may lower the blood pressure, cause some weight loss and do not cause low blood sugar. They are also beneficial for the heart and kidney functions. Local yeast infections (in the genital area) may occur and rare cases of DKA (diabetic ketoacidosis) have been reported. If your oral intake is very low or you are not eating, you will need to stop the medicine temporarily.
- GLP-1 analogs (Bydureon®/Victoza®/Trulicity®/Ozempic®/Rybelsus®):
These agents, slow absorption of the carbs and reduce appetite. Many patients lose weight, and some may complain of nausea in the first weeks of use. Very rarely, a serious complication called pancreatitis (severe abdominal pain) may occur. In animal studies, thyroid cancer was seen rarely. GLP-1 analogs reduce heart related complications in patients with diabetes. They are given as injections (via disposable pens – just under the skin via prefilled pen-like devices), usually once a week.
- Actos® (Pioglitazone):
Actos improves insulin resistance and lowers blood fat levels in
many patients. If used early, it may slow down deterioration of insulin producing capability of the pancreas. It can cause weight gain, fluid retention, increased risk of fractures of small bones and should not be used if a patient has congestive heart failure or is at increased risk of heart failure. In some studies, long term use of higher doses of pioglitazone was linked to an increased risk of bladder cancer. Usually, people take it with breakfast once a day.
They stimulate release of insulin from the pancreas. Therefore, these medications should be taken once or twice a day (before a meal). Because they may deplete existing insulin stores in the pancreas, they should be avoided if blood sugars are not too high. They can cause eight gain and sometimes severe hypoglycemia can occur. Examples: Glimepiride, Glipizide and Glyburide.
They also stimulate release of insulin from the pancreas, but it is for shorter periods. They should be taken once to three times a day (before a meal). Examples include Prandin® (repaglinide) or Starlix ® (nateglinide). If you do not eat a meal, do not take it (in general).
- DPP-4 Inhibitors (Januvia®/Onglyza®/Tradjenta®/Alogliptan):
These are often used with other medicines, have few side-effects & do not cause hypoglycemia (low BG). They are more effective in lowering BG peak after meals. Generally, these medications are taken once daily and may be taken in the morning or evening (before or after a meal). Side effects are uncommon but acute pancreatitis may occur rarely.
Insulin is the most effective agent to lower BG & if BG levels are really high, or diabetes has been present for >6-8 years, insulin production from your pancreas may be too low. Therefore “pills” may not be able to keep your BG under control (particularly after meals) and you may have to add insulin to your regimen. Your doctor will recommend the best combination depending on the severity of your diabetes (see article on insulin therapy).
Diabetes is a chronic disease. By taking charge, you can control it and prevent all of the complications of diabetes. American Diabetes Association (www.diabetes.org) has many publications and other tools that may help you control your diabetes. Good luck!!
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