Choosing the Best Diabetes Medications for You

Choosing the Best Diabetes Medications for You

Managing Type 2 Diabetes: A Comprehensive Guide to Medication Options

You have been diagnosed with type 2 diabetes. What are your medication options? That depends on what type of diabetes you have and what risk factors you carry.

In type 2 diabetes, the body becomes resistant to insulin, and the pancreas has to make more. Insulin resistance can be caused by various factors such as obesity, lack of exercise, medication, stress, or hereditary factors. Initially, the pancreas compensates by producing more insulin, but over time, it can tire out, leading to insufficient insulin production. The management of glucose levels in diabetes involves a combination of diet, exercise, weight loss, and medication.

Screening and Risk Factors

Symptoms of diabetes include excessive urination, excessive thirst, urinary tract infections, genital yeast infections, weight loss, blurry vision, and fatigue. Interestingly, the most common symptom of diabetes or high glucose is no symptoms at all. Therefore, it is crucial, especially if you have risk factors, to undergo screening for diabetes. Risk factors include obesity, family history, personal history of gestational diabetes, use of certain medications like steroids or HIV medications, fatty liver disease, prediabetes, polycystic ovarian syndrome (PCOS), or high triglyceride levels.

Choosing the Right Medications

With 12 classes of diabetes medications, each with its own mechanism of action and tongue-twisting names, it’s no wonder patients may feel confused about which medication is right for them. The American Diabetes Association (ADA) recommends that the decision on which medications to use be made collaboratively between the patient and their doctor, taking into account factors such as cost, beneficial effects on heart and kidney disease, long-term risk of hyperglycemia, life expectancy, desire for pregnancy, and risk of hypoglycemia.

Compelling Indications for Newer Diabetes Medications

For patients with heart or kidney disease, newer medications called GLP-1 agonists and SGLT2 inhibitors have shown to be beneficial. These medications have been found to reduce the risk of heart attack, stroke, admission for heart failure, progression of kidney disease, and the need for dialysis. According to the ADA, patients with blockages in the heart arteries, a history of heart attack or heart failure, chronic kidney disease, or high levels of urinary protein called albumin should consider taking GLP-1 agonists or SGLT2 inhibitors. SGLT2 inhibitors are preferred for patients with albumin-creatinine ratio (uACR) levels over 200 mg/g and for patients with a history of heart failure.

Medication Classes and their Considerations

  1. Metformin: This medication helps the liver recognize insulin and reduces glucose levels. It is generally well-tolerated, although it may cause gas and diarrhea. It should not be used in patients with stage 4 or 5 chronic kidney disease.

  2. Sulfonylureas: Sulfonylureas increase pancreatic insulin secretion but can cause hypoglycemia, especially in elderly patients. They are a cost-effective option but should be discontinued if recurrent hypoglycemia occurs.

  3. SGLT2 Inhibitors: These medications work by taking glucose from the blood and excreting it in the urine. They may increase the risk of urinary tract infections and genital infections. It is crucial to maintain hydration and adjust blood pressure medications if necessary.

  4. GLP-1 Agonists: GLP-1 agonists increase insulin secretion, slow gastric emptying, and increase satiety. Some of these medications are injectable, while one comes in a pill form. Nausea, vomiting, and the uncertain association with pancreatitis and pancreatic cancer should be considered.

  5. Dual GIP/GLP-1 Agonists: Tirzepatide (Mounjaro) is a medication that combines the actions of GLP-1 agonists and gastric intestinal peptide (GIP). It lowers glucose levels and leads to more significant weight loss than GLP-1 agonists alone.

  6. Thiazolidinediones: These medications improve insulin resistance and can recruit cells to take in extra glucose. They effectively lower glucose levels but can cause weight gain, volume overload leading to heart failure, and swelling.

  7. DPP-IV Inhibitors: DPP-IV inhibitors slow the breakdown of natural GLP-1, thereby extending its lifespan. They do not cause nausea and vomiting but have a weaker effect compared to GLP-1 agonists. Like GLP-1 agonists, they have an uncertain link to pancreatic cancer and pancreatitis.

Insulin and Other Considerations

Many patients with type 2 diabetes are insulin-deficient or unable to produce sufficient insulin. Starting insulin therapy may be necessary if glucose levels do not respond to other medications and lifestyle changes. Patients with specific conditions, such as infections, non-healing wounds, or weight loss, may benefit from insulin therapy. Additionally, patients with a history of pancreatic insufficiency or those with type 1 diabetes require insulin.

When considering these medications’ benefits, it is important to be aware of potential side effects and contraindications. However, with a range of options available, along with exercise and a healthy diet, individuals with type 2 diabetes can find a regimen that suits them and helps maintain or improve glucose control.

By following the guidance of healthcare professionals and staying informed about the different classes of medications, individuals with type 2 diabetes can effectively manage their condition and improve their overall health and well-being.

By Susan E. Spratt, MD Associate Professor of Medicine, Duke University School of Medicine
HealthDay Reporter