Type 2 Diabetes Medications

    
Kiah Connolly, MD

Type 2 diabetes develops when the body can’t use insulin like it’s supposed to. Without insulin, the body builds up high amounts of glucose (aka blood sugar). High blood glucose levels can cause many problems and often needs to be controlled with medications. 

Unfortunately, all medications can impose undesirable side effects. 

Lifestyle changes involving increased exercise, diet modifications and weight loss are the most ideal way to treat type 2 diabetes

While it is accepted and often encouraged to give diet and exercise a trial before starting medications, such major changes in daily routines can be very challenging and they require consistency and time to reap results. Unfortunately many people don’t  implement enough of these lifestyle changes before medications are strongly recommended. 

If you’re motivated to make a difference to get your diabetes under control without any pills or injections, don’t get discouraged.

It's always important to take all of your medications as prescribe by your doctor. However, you may be eventually be able to stop taking diabetic medication completely with the right diet modifications, regular exercise and weight loss. 

This article was created to give you a better understanding of the most common types of medication used to treat diabetes including basics on how they work, some benefits they offer, and the most common side effects to watch out for.

Metformin (Glucophage)

Metformin is usually the first medication chosen to help people with type 2 diabetes. 

So why has metformin become the darling of diabetes? 

Metformin works by helping decrease glucose production by the liver and helping insulin that’s already in the body work better. In other words, Metformin improves the effect of insulin. This is sometimes referred to as tissues and cells in the body becoming ‘more sensitive to insulin’. 

Metformin Pros 

  1. Comparatively Inexpensive
  2. Relatively Few Side Effects
  3. Can Help Weight Loss
  4. Can Improve Cholesterol
  5. Can be Good for Heart Health

Metformin is comparatively one of the most affordable medications for type 2 diabetes with most insurances.  It is also tolerated well by most people. 

Metformin doesn’t cause hypoglycemia or weight gain like some of the other diabetes medications. It can also be taken with many other medications for diabetes if additional control is needed. 

Metformin may offer additional perks including helping to decrease the risk of heart attacks and other cardiovascular complications in people with diabetes. And it also may help with weight loss and lowering lipid profiles (LDL and triglycerides). 

Metformin Cautions

  1. Gastrointestinal Side Effects 
  2. Lactic Acidosis
  3. Vitamin B12 Deficiency
  4. Kidney Disease

Gastrointestinal Side Effects

The most common side effects of metformin is an upset stomach. This includes nausea, vomiting and diarrhea. 

 Your doctor may suggest that you start on a lower dose of the medication and increase it slowly. Once your body becomes used to the medication with this more gradual adjustment these side effects often go away. 

Quick Tip: Always take Metformin with food to help prevent feeling an upset stomach. 

Lactic Acidosis 

Although rare, a condition called lactic acidosis is arguably the most serious potential side effect of metformin.  Unfortunately the condition is difficult to identify because the symptoms aren’t always very obvious and are nonspecific. 

Lactic acidosis is most often exacerbated by metformin when there is decreased oxygen to the cells in situations such as: 

  • Serious Illness 
  • Kidney Failure
  • Heart Failure 
  • Dehydration 
  • Advanced Liver Failure

Vitamin B12 Deficiency 

Vitamin B12 deficiency can occur in some people taking metformin. Effects of Vitamin B12 deficiency can include anemia (low hemoglobin counts) and numbness or tingling in your hands or feet (called peripheral neuropathy).

The good news is that simple blood tests can identify this problem and it’s not immediately dangerous. Your doctor may have you take additional vitamins if you are found to have low vitamin B12 in order to help your deficiency. 

Sulfonylureas 

Another very common diabetic medication class is called sulfonylureas. These can either be taken alone or in combination with metformin - and sometimes other medications.  

Sulfonylureas work by stimulating insulin secretion leading to more insulin in the body.  

Sulfonylurea Medication List: 

  • Glyburide (DiaBeta, Glynase, Micronase) 
  • Glimepiride (Amaryl) 
  • Chlorpropamide (Diabinese) 
  • Glipizide (Glucotrol)
  • Tolazamide (Tolinase)

Sulfonylurea Pros

  1. Comparatively Inexpensive
  2. Relatively Few Side Effects

Sulfonylureas are often tolerated very well with the most common side effect being low blood sugar. 

Sulfonylurea Cautions  

  1. Hypoglycemia (low blood sugar) 
  2. Weight Gain
  3. Increased Liver Function Tests (rare)

One of the most dangerous complications of this medicine is low blood sugar. What’s more is that some of these medications can cause recurrent episodes of low blood sugar over the course of the following 24 hours. Therefore sometimes people are watched in the hospital for an extended observation period when they have low blood sugar on these medications. 

 A very relevant and unfortunate consequence of this class of medications is the possibility of weight gain. Because weight loss is such a critical part of diabetes treatment it is important to carefully monitor any significant weight gain on these medications. 

Alpha Glucosidase Inhibitors 

These medications help blood glucose control by excreting excess glucose from the body into the urine. 

Alpha Glucosidase Inhibitor Medication List 

  • Acarbose (Precose) 
  • Miglitol (Glyset)

Alpha Glucosidase Inhibitor Pros 

  1. Relatively Few Side Effects
  2. Decreases Risk of Heart Disease
  3. Decreases Risk of Stroke

Alpha Glucosidase Inhibitor Cautions 

  1. May Cause Low Blood Pressure 
  2. Increased Risk of Infections 
  3. Increased Risk of Diabetic Ketoacidosis 

Meglitinides 

While they are still considered a different medication class, meglitinides are very similar to sulfonylureas. While the sulfonylurea class is often tried first, meglinitides are sometimes used in people who have allergies to sulfonylureas. 

Similar to sulfonylureas, meglitinides work to control blood sugar levels by stimulating the pancreas to release more insulin. 

Meglitinides Medication List

  • Repalginide (Prandin)

  • Nateglinidie (Starlix)

Meglitinide Pros 

  1. Relatively Few Side Effects 
  2. Safe in Kidney Disease (repalginide)  

While there needs to be caution in using some diabetic medications for people with kidney disease, repalginide seems to not make kidney function worse and is therefore sometimes chosen for people with diabetes and kidney problems. 

Meglitinide Cautions

  1. Hypoglycemia 
  2. Weight Gain
  3. Liver Problems
  4. Medication Interactions

 The risk of weight gain is similar to sulfonylureas and should always be carefully monitored, especially since weight loss is such an important treatment for  type 2 diabetes. 

Because the liver processes these medications, people with significant liver problems are probably not a good fit for this medication class. You should also always make sure to follow up with blood tests your doctor orders.

Thiazolidinediones

These medications work by helping insulin to work better. Similar to metformin, it makes the body cells more sensitive to insulin. 

Thiazolidinedione Medications Include:

  • Rosiglitazone (Avandia)
  • Pioglitazone (Actos)

Thiazolidinediones Pros 

1. Relatively Inexpensive 

Thiazolidinediones Cautions 

1. Weight Gain 
2. Low Blood Counts (Anemia)

3. Increased Risk of Heart Failure

GLP-1 (Glucagon-like-peptide-1) Agonists

 GLP-1 medications include GLP-1 receptor agonists which are injections and DPP-4 inhibitors (dipeptidyl peptidase 4 inhibitors) which are oral medications. 

GLP-1 Receptor Agonists Medication List

  • Exenatide (Byetta) 
  • Liraglutide (Saxenda) 
  • Lixisenatide (Adlyxin)
  • Albiglutide (Tanzeum)
  • Dulaglutide (Trulicity)

GLP-1 Pros

  1. Low Risk of Hypoglycemia
  2. Weight Loss
  3. Low Risk of Heart Problems  

GLP-1 Cautions

  1.     Require Injections
  2.     Expensive (for most insurances)
  3.     Nausea & Vomiting
  4.     May Cause Kidney Problems
  5.     May Exacerbate Pancreatitis

Unfortunately these medications are only able to be given as an injection. Many people may prefer oral medications over a daily shot if they have a choice! Depending on what insurance coverage you have, these medications may be more expensive when compared to other diabetic treatments. 

Taking this medication with food can help symptoms of upset stomach better. It’s important to follow up with lab tests that your doctor orders to make sure your kidney function isn’t worsening.

People with severe kidney disease may not be prescribed these medications. 

There have been some reports that GLP-1 medications can increase the risk of pancreatitis in people who are already susceptible to it. Because of this some people recommend not taking these medications if you have had pancreatitis in the past. 

DPP-4 inhibitors (Dipeptidyl peptidase-4 inhibitors)

 

This medication class works to lower blood sugars in many different ways including stimulating insulin release and slowing down gastric emptying. They also decrease the “extra release” of glucagon after a meal which helps the insulin that is available to work better. 

 

DPP-4 Inhibitor Medication List 

  • Sitagliptin (Januvia)
  • Vildagliptin (Galvus)
  • Saxagliptin (Onglyza)
  • Linagliptin (Tradjenta)

DPP-4 Inhibitor Pros

  1. Low Risk of Hypoglycemia
  2. Safe in People with Kidney Disease
  3. Weight Neutral

DPP-4 Cautions

  1. More Expensive (for most insurances)
  2. Possible Increased Risk of Heart Failure Hospitalizations
  3. Possible Increased Infections
  4. Possible Increased Risk of Liver Enzyme Elevation 
  5. Increased Risk of Rash
  6. Increased Risk of Joint Pain

DPP-4’s can be relatively more expensive than other diabetic medications, depending on the insurance coverage you have. Studies showing an increased risk of hospitalizations in people with congestive heart failure (CHF) who take DDP-4 medications has led to concern and often limiting their use in people with heart problems. 

If you start to have a rash while taking these medications, they may be the cause. While most of these rashes aren’t dangerous, many people stop taking the medication when this occurs. 

SGLT2 Inhibitors (Sodium-Glucose Cotransporter 2 Inhibitors)

These medications work by getting rid of glucose in the urine.

SGLT2 Inhibitor Medication List

  • Canagliflozin (Invokana) 
  • Dapagliflozin (Farxiga)
  • Empagliflozin (Jardiance)

SGLT2 Inhibitor Pros 

  1. Lower Risk of Heart Problems 
  2. May Help Decrease Blood Pressure
  3. Weight Loss 
  4. Low Risk of Hypoglycemia 

 Similar to DDP-4’s. SLGT2 medications may have a positive influence on the whole picture of diabetes by helping to decrease blood pressure, assisting in weight loss and lowering the risk of heart disease.

SGLT2 Inhibitor Cautions

  1. Comparatively Expensive (for most insurances)
  2. May Increase Risk of Infections
  3. May Cause Low Blood Pressure (dizziness)
  4. Possible Increased Risk of Broken Bones
  5. Possible Negative Effects on Kidneys 
  6. Possible Increased Risk of Bladder Cancer

These medications are often comparatively more expensive than some of the other diabetic medications, depending on your insurance. While these medications have of course been approved by the FDA which involves significant safety date, there isn’t yet quite as much research as some of the other diabetic medications. 

 While lowering blood pressure in many people who have hypertension is a good medication effect, SGLT-2 Inhibitors can make blood pressure too low sometimes - especially in people who don’t have hypertension. If the blood pressure gets too low then this can lead to dizziness, falls and passing out. 

 These medications may also lead to more infections and an increased risk of broken bones.  Some people think the increased falls causing broken bones may be due to dizziness from low blood pressure. 

 Your doctor may check your kidney function regularly while on this medication to make sure there aren’t any problems. There was an increased association of bladder cancer identified in people taking this medication. More studies need to be performed to find out what this risk really is.

Insulin 

While many oral medications are usually tried first, some people with advanced type 2 diabetes will need insulin injections. And all type 1 diabetics need insulin injections. 

To learn more about insulin, read this article. 

Other Diabetic Medications 

A main goal of treating diabetes is to lower the risk factors of dangerous diabetes consequences like stroke and heart attacks. 

Therefore your doctor may put you on other medication that can help decrease the risk of other comorbid conditions. A baby aspirin is often included for heart health as are other medications used to treat high blood pressure (hypertension) and high cholesterol (hypercholesterolemia)

Don’t forget that no matter what medications you’re taking, a proper diabetic diet and regular exercise are also critical for your overall health and diabetes treatment.   






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