OK, you’ve been diagnosed with type 2 diabetes and now your job is to manage your blood sugar levels and lower your risk for complications such as heart disease, vision problems, kidney disease, and nerve damage.
Maybe you’ve had diabetes for a while, or perhaps you’re new to this challenge. Either way, the treatment that’s best for you will depend on the severity of your diabetes and your health overall. If you’re diagnosed relatively soon after developing the condition, you may need less help controlling your blood sugar than if you’ve been living with the illness for many years.
“The way we think of diabetes is, one goes almost through stages,” says Robert Gabbay, MD, PhD, chief medical officer at Joslin Diabetes Center in Boston. “In the early stages, lifestyle changes are enough. Then you need metformin (Fortamet, Glucophage, Glumetza, and other brands). Then you might need two drugs to control it, or three drugs, and then eventually require insulin. That progression through those different stages can take a variable amount of time.”
Throughout your life with type 2 diabetes, your doctor may recommend some of the following treatment options:
Eat Well, Move More, Lose Weight
Sometimes, type 2 diabetes can be managed well without medication. Your doctor may recommend weight loss, diet changes, and regular physical activity. “A healthy lifestyle has been shown to delay a need for medications by many years, and I have seen many people who can decrease, or even discontinue, their medications by losing weight with a healthy diet and exercise plan,” says David C. Klonoff, MD, clinical professor of medicine at the University of California, San Francisco, and medical director of the Diabetes Research Institute of Mills-Peninsula Medical Center in San Mateo, California.
Most people with type 2 diabetes are overweight or obese (though some are lean). If you’re on the heavy side, your doctor may suggest meeting with a registered dietitian to come up with an eating plan that includes some of your favorite foods, so you’re more likely to stick with the plan.
Losing even a small amount of weight can have other profound effects on your health. For example, one landmark study showed that adults with type 2 diabetes who lost about 10 percent of their body weight significantly lowered their risk of heart disease. “You get most of the benefit of weight loss for the first 5 or 10 percent,” Dr. Gabbay says. “That relatively small amount of weight loss can have a big impact metabolically, to improve blood sugar, cholesterol, and blood pressure.” Another key part of treating type 2 diabetes is to find a spot in your daily routine to fit in fitness activities, which can make your body more sensitive to insulin and help you better control your blood sugar.
Metformin to Start
If you can’t control your blood sugar levels with diet, exercise, and nutritious food, the first drug that your doctor will probably prescribe is metformin. This medication can make your body respond more sensitively to the insulin in your system, in addition to prompting your liver to produce less glucose.
And the benefits don’t end there: You may also lose weight. “Metformin is one of the oldest and best type 2 diabetes medications we have, and studies have shown its benefits time and time again,” says Farah Khan, MD, assistant professor of metabolism, endocrinology, and nutrition at the University of Washington School of Medicine in Seattle. “Metformin is also a very-low-risk medication, which is why it is safe to start in most patients.”
Many people take metformin successfully for years. If it becomes less effective over time, your doctor may recommend that you combine it with other medications, or switch to another drug.
Meds With Special Effects
If you need something more than lifestyle changes and metformin to manage your diabetes, there are numerous drugs available. Some classes of meds have unique advantages for certain groups of people. For instance, one type of drug may be preferable to another if you have another condition, such as heart disease or a difficult weight problem.
Another consideration is how high your blood sugar levels are and “what will likely get you to your goal,” says Dr. Gabbay. Additionally, some drugs are cheaper than others, so that aspect may come into play if cost is an issue. And some are available only by injection. If you prefer taking pills, let your doctor know so that can be taken into account.
“Ideally, it’s a shared decision with the patient,” points out Dr. Gabbay. Some people need two or more drugs to get their diabetes well controlled. In this case, your doctor may prescribe a combination medication containing two drugs. This approach may cost less out of pocket since you’ll only have one co-pay. And taking one pill, as opposed to two, may make it easier to stay on track.
The Goal: Lower Your A1C
Several classes of drugs are used to treat diabetes, and they work in different ways to lower blood glucose levels.
- Sulfonylureas and meglitinides are two classes of medications that stimulate the pancreas to secrete more insulin. Sulfonylureas include chlorpropamide (Diabinese), glimepiride (Amaryl), glipizide (Glucotrol), and glyburide (DiaBeta, Glynase). Meglitinides include nateglinide (Starlix) and repaglinide (Prandin). These drugs may cause weight gain or low blood sugar levels, but they’re less expensive and taken only once a day.
- Thiazolidinediones, which include the drugs pioglitazone (Actos) and rosiglitazone (Avandia), help your body become more sensitive to the insulin that’s already in your system. These medications may not be right for some because of possible side effects such as fluid retention and worsening of heart failure.
- GLP-1 receptor agonists mimic a naturally occurring hormone that triggers the production of insulin after you eat. These injectable drugs include dulaglutide (Trulicity), exenatide (Byetta), liraglutide (Victoza), lixisenatide (Adlyxin), and semaglutide (Ozempic). They are also associated with weight loss, and some of them lower the risk of heart disease.
- DPP-4 inhibitors are preferable for some people. “DPP-4 inhibitors have many of the same benefits as GLP-1 receptor agonists, but to a less pronounced effect, because of the indirect method by which these medications work,” Dr. Khan says. They include alogliptin (Nesina), linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia).
- SGLT2 inhibitors keep the body from reabsorbing sugar from the urine. The most recent drug in this class to be approved by the U.S. Food and Drug Administration (FDA) is ertugliflozin (Steglatro), which can be taken on its own once daily or with the DPP-4 inhibitor sitagliptin in a combo pill called Steglujan. Ertugliflozin has also been approved for use with metformin. Other SGLT2 inhibitors are canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance). Like GLP-1 receptor agonists, these oral meds have been found to lower heart disease risk.
Time for Insulin?
Over time, if other medications and strategies haven’t been effective, your doctor may recommend insulin. People “reach a point where you can help the body make insulin and you can make it very sensitive to the insulin, but there’s just not enough around,” Dr. Gabbay says. “You’re now having to replace the hormone the body doesn’t make enough of.”
Insulin goes by many different names, and there are several types. The insulin prescribed to you will be customized to you and your needs. Many people inject rapid-acting insulin before meals, but there are also longer-lasting forms that may be injected once or twice a day. Some people choose to wear an insulin pump, which is a computerized device that administers insulin throughout the day through a small needle connected to the pump and taped onto the body. Regardless of how you get insulin into your body, you’ll need to check your blood sugar levels often.
Bariatric Surgery: Risky but Effective
One way to tackle type 2 diabetes and obesity at the same time is to have bariatric surgery, which is a catch-all name for procedures on the stomach or intestines designed to instigate weight loss.
Research shows that up to 75 percent of people who undergo gastric bypass surgery (a form of bariatric surgery) experience remission from diabetes, eliminating the need for medication or other treatments. And even if remission doesn’t happen, bariatric surgery helps with blood sugar control and weight loss.
However, bariatric surgery is a major procedure and can involve significant risks. Talk to your doctor about whether it’s an option for you.
New Tech and Drugs
Many positive changes have come to type 2 diabetes treatment in recent years, including a number of new FDA-approved drugs. And technology is making it easier for people to manage the disease. “Diabetes patients are able to benefit right now from many bioengineered tools,” Dr. Klonoff says, “such as wearable sensors, insulin pumps, personalized software on their smartphones, and new types of medication delivery systems—while we await development of a cure.”