Finding the Best Type 2 Diabetes Treatment: Factors to Consider

There are several classes of medications used to treat type 2 diabetes.

Metformin is generally the preferred initial medication for treating type 2 diabetes unless there’s a specific reason not to use it. Metformin is effective, safe, and inexpensive. It may reduce the risk of cardiovascular events.

Metformin also has beneficial effects when it comes to reducing A1C results. It may also help with weight management. It works by reducing glucose production by the liver.

There are other classes of diabetes medications available. Each class has its own risks and benefits.

Sulfonylurea

Medications in this class include glipizide, glyburide, and glimepiride. These medications can be inexpensive but may cause low blood sugar levels and weight gain.

Insulin sensitizer

This medication, pioglitazone, is effective and has no risk of hypoglycemia (low blood sugar). However, it can lead to weight gain.

Glucagon-like peptide-1 (GLP-1) receptor agonists

There are several types of this medication available, including exenatide (Byetta, Bydureon), liraglutide (Victoza, Saxenda), and dulaglutide (Trulicity). Some of these medications are given by daily injection, and others by weekly injection.

There is also an oral form of semaglutide (Rybelsus) that can be taken once per day. This type of medication is effective, and may be beneficial for the heart and help with weight loss. But it may also cause side effects, such as nausea and diarrhea.

Dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors)

There are several medications available in this class. They’re all brand-name drugs, including sitagliptin (Januvia), saxagliptin (Onglyza), and linagliptin (Tradjenta).

They’re all easy-to-use, well-tolerated oral medications taken once a day. They have a mild effect on reducing blood sugar levels. Mainly, they reduce postmeal blood sugar levels.

Alpha-glucosidase inhibitor

This medication, acarbose, is rarely used. It causes flatulence and decreases carbohydrate absorption.

Sodium-glucose cotransporter-2 inhibitors (SGLT-2 inhibitors)

This is the newest class of diabetes medications. They lower blood glucose levels by removing glucose from the body through urine. There’s growing evidence that this class provides cardiovascular benefits, apart from the benefits of improved blood glucose management.

Growing evidence is also finding benefits for the kidneys, such as slowing the progression of chronic kidney disease (CKD). Medications in this class are all brand names, including empagliflozin (Jardiance), dapagliflozin (Farxiga), canagliflozin (Invokana), and ertugliflozin (Steglatro).

Type 2 diabetes is a complex, chronic condition. Managing it effectively means using multiple risk-reduction strategies while also achieving your target goal for blood sugar control.

To decide which treatment plan will benefit you the most, your doctor will consider the following factors:

• presence or absence of heart disease, which includes a history of heart attacks, strokes, or congestive heart failure
• presence or absence of chronic kidney disease (CKD)
• the risk of low blood sugar with any particular therapy option
• potential side effects of treatment
• your weight and the potential for the treatment to affect weight
• cost of the medication and insurance coverage
• your individual preferences and if you think you’ll be able to stick with the treatment plan

Your doctor will also consider your A1C test results, which provide information about your average blood sugar levels over the last 3 months.

Metformin is usually the first medication recommended for type 2 diabetes unless there are specific reasons not to use it. Your doctor may prescribe other medications at the same time as metformin, if you need them.

Each medication generally lowers an individual’s A1C level by a certain amount. Some medications are more effective and can reduce A1C by 1 to 1.5 percent. Others may only reduce it by 0.5 to 0.8 percent.

For most people, the goal of treatment is to lower your A1C below 7 percent. This target is set by the American Diabetes Association guidelines, though your doctor will help you establish the right A1C goal for you. If an individual’s A1C is over 9 percent, the doctor may recommend starting two medications at the same time.

Your doctor will also emphasize that lifestyle changes are an important part of your overall treatment plan for type 2 diabetes.

Type 2 diabetes occurs due to a combination of two issues. The first is insulin resistance. This means the body can’t use insulin as effectively as it once did. The second is the body’s inability to produce enough insulin to compensate for the degree of insulin resistance that an individual is experiencing. We call this relative insulin deficiency.

There are different degrees of insulin deficiency. Insulin may be introduced early in the course of a person’s treatment if they have symptoms of high blood sugar, along with weight loss, A1C levels over 10 percent, or a random blood sugar test over 300 milligrams per deciliter (mg/dL).

People whose blood sugar levels aren’t that high can usually achieve target glucose control with non-insulin medications. That means they don’t need insulin therapy at this point in their treatment.

Lifestyle measures are one of the most important therapies for type 2 diabetes. They should be incorporated into all treatment plans and decisions.

If a person is able to manage their diet, weight, and physical activity level, they’re more likely to achieve good management of their blood sugar levels. At that point, their medication plan can be modified and simplified.

Many people who need to take insulin are able to stop taking it if they’re successful in maintaining healthy lifestyle habits. Never stop taking a medication without speaking to your doctor first.

If you’re taking certain medications for another condition, it may affect which therapies are the best option for treating type 2 diabetes.

Many medications can affect your type 2 diabetes treatment plan. For example, steroid therapy, which may be needed for various skin or rheumatological conditions, may increase blood sugar levels. In turn, this means modifying an individual’s diabetes treatment plan.

Many chemotherapy drugs can also affect the choice of which diabetes medication is right for an individual.

Many people who live with type 2 diabetes also need treatment for high blood pressure and cholesterol levels. The most common medications used to treat these conditions don’t interact with diabetes therapies.

If a treatment isn’t working, you may experience progressively increasing blood sugar levels. The most common symptoms that may appear if your blood sugar levels are rising include:

• feeling thirsty
• urinating more frequently
• getting up at night several times to urinate
• blurry vision
• losing weight without effort

If you experience these symptoms, it’s a sign that elevated blood sugar levels need to be addressed immediately. It’s very important to notify your doctor about these symptoms as soon as possible. If these symptoms become severe before you can see your doctor, consider going to the emergency room for an evaluation.

Marina Basina, MD, is an endocrinologist specializing in diabetes mellitus type 1 and 2, diabetes technology, thyroid, and adrenal disorders. She graduated from Moscow Medical University in 1987 and completed her endocrinology fellowship at Stanford University in 2003. Dr. Basina is currently a clinical associate professor at Stanford University School of Medicine. She’s also on the medical advisory board of Carb DM and Beyond Type 1, and is a medical director of inpatient diabetes at Stanford Hospital.

In T2D, the body doesn’t respond properly to insulin. This leads to high blood glucose (sugar) levels. Your primary care practitioner handles everyday health questions. They may refer you to an endocrinologist, who specializes in diabetes. Endocrinologists monitor blood glucose levels, prescribe treatments such as lifestyle changes and medication, and help manage risks for T2D complications.

Treating T2D often requires lifestyle changes. A certified diabetes care and education specialist (CDCES) is a registered nurse, physician assistant, or other health professional who has special training to help people manage diabetes. They’ll help you navigate changes to your diet, exercise, sleep schedule, or other habits to meet your treatment goals.

A well-managed diet helps regulate your blood glucose levels, may help you lose weight, and reduces your risk of diabetic complications. A registered dietitian can design a sustainable, balanced diet that can help you to manage T2D.

High blood glucose levels can damage nerves and reduce blood flow to your feet. This may lead to slow-healing infections that you might not notice, which could eventually require amputation. A podiatrist specializes in foot care. They prescribe treatment for infections as necessary and teach you how to care for your feet and conduct regular foot exams.

Diabetic retinopathy is nerve damage in the eye caused by high blood glucose levels. It can eventually lead to vision loss. It’s important to visit an ophthalmologist or optometrist for regular eye exams. These doctors specialize in eye health and may prescribe treatment like medication or surgery for eye diseases and disorders.

Many people with T2D have high blood pressure and cholesterol. All three conditions raise the risk of heart attack and stroke. A cardiologist specializes in heart disease. They may prescribe treatment such as lifestyle changes and medication to lower cholesterol and blood pressure and reduce the risk of heart problems.

High blood sugar can damage blood vessels in the kidneys, which raises your risk of chronic kidney disease (CKD). You should get regular blood tests to check for CKD. If you develop advanced or complicated CKD, your doctor will refer you to a nephrologist. This doctor specializes in kidney disease and will prescribe treatments such as lifestyle changes, medication, and dialysis.

T2D raises the risk of anxiety and depression. A psychologist, clinical social worker, or licensed counselor can diagnose and treat mental health conditions with psychotherapy. A psychiatrist can prescribe medication if needed.