By Chris Iliades, MD Medically reviewed by Niya Jones, MD, MPH
When you think of diabetes medication, you probably think of insulin. In many cases, treatment for type 2 diabetes may never actually involve insulin replacement. Although type 2 diabetes is caused by a failure of the body to make or properly use its own insulin, a hormone needed for blood sugar control, there are many treatment plans for type 2 diabetes without insulin replacement.
“You could say that everybody with type 2 diabetes will eventually need insulin if they lived long enough,” explains Kevin M. Pantalone, DO, an endocrinologist and diabetes expert at the Cleveland Clinic in Ohio. “But in reality, only about 20 to 30 percent of people with type 2 diabetes ever need it. We have lots of other options we can use first.”
First-Line Options: Diet, Exercise, and Metformin
“Diet and exercise alone were once the standard diabetes therapies for early type 2 diabetes, but that has changed over the past few years,” Dr. Pantalone says. “The American Diabetes Association (ADA) now recommends starting the diabetes medication metformin early. Today, only a minority of people are prescribed diet and exercise alone for diabetes.”
According to a review of type 2 diabetes management plans published in the journalClinical Diabetes in 2012, metformin should be used as initial therapy for type 2 diabetes because it can lower A1C by 1 to 2 percent.
A1C is a blood test that measures your average blood sugar over the past two to three months. The goal is to have an A1C score of 7 percent or less. Doctors use this measurement to decide on treatment options from lifestyle changes and oral medications to insulin replacement.
Here’s more on the first-line treatments for diabetes:
A diabetes diet. A healthy diet is importantfor controlling blood sugar, maintaining a healthy weight, and reducing the risk of other health conditions, like heart disease. “For most people, a diabetes diet means sticking to a healthy diet of 1,800 calories a day,” Pantalone says. “People with type 2 diabetes need to learn how to count calories and spread out their carbohydrates throughout the day.” Working with a certified diabetes educator and nutritionist can help you with your diet to manage diabetes.
Exercise for diabetes. Exercise can slow the progression of diabetes and make it easier to manage. Beyond helping with weight loss and improving overall health, exercise has a direct effect on blood sugar. The ADA recommends that people with type 2 diabetes get at least 150 minutes of exercise a week, or 30 minutes a day on five days of the week. People with diabetes who need to lose weight should try to lose 15 to 20 percent of their body weight, Pantalone advises.
Metformin. Metformin works by decreasing your liver’s production of glucose (sugar) and increasing the body’s sensitivity to insulin.” Most people start metformin at one or two times per day, and the dose is raised gradually to prevent side effects like nausea and diarrhea,” Pantalone says. Metformin is generally used along with diet and exercise for three months. If an A1C of less than 7 percent is not achieved by then, another diabetes medication may be added.
Type 2 Diabetes Treatment After Metformin
If metformin and lifestyle changes are not enough to control blood sugar, your doctor will adjust your treatment plan. “When metformin fails, treatment gets more complicated,” Pantalone says. “We now have many oral diabetes medications as well as non-insulin injectable medications as options.” However, he notes that there are no hard and fast guidelines for what to try after metformin, so treatment needs to be individualized for each person.
Here are common classes of diabetes medication that may be added to your type 2 diabetes treatment plan:
Sulfonylureas. These diabetes drugs have been around since the 1950s. They work by increasing the body’s insulin production. The reason they’re not considered frontline treatment is that they can sometimes cause blood sugar to dip too low (hypoglycemia) and may cause weight gain.
Meglitinides. These diabetes medications are short-acting, so they need to be taken three times a day, before meals. They work by stimulating cells in the pancreas to secrete more insulin.They’re less likely to cause hypoglycemia, but they typically lower A1C by 1 percent or less.
Thiazolidinediones. These drugs act by decreasing insulin resistance. They do not cause hypoglycemia, but they only lower A1C by up to 1.5 percent. Recent evidence suggests that while thiazolidinediones can boost “good” HDL cholesterol, they may increase the risk of heart failure, so they should not be used by people with congestive heart failure, and people who use these drugs should be monitored for potential heart problems. They can also cause weight gain.
Alpha-glucosidase inhibitors. These diabetes medications slow the rise in blood sugar by stopping the breakdown of starches in foods like bread and potatoes as they’re being digested. When the medicine is taken just before eating, it slows down the rise in blood sugar after the meal. Their use is limited because they are not as effective as other types of diabetes drugs, and commonly cause side effects of bloating and diarrhea.
Incretin agents. These include the medications GLP-1 and DPP-4 inhibitors. GLP-1 works by stimulating insulin secretion and slowing down digestion. It can lower A1C and may stimulate weight loss. DPP-4 inhibitors help your body use its own compound that reduces blood sugar.
Non-insulin injectable drugs. Exenatide is an injectable diabetes drug that increases insulin secretion, but it may cause nausea. An extended-release version of the drug can be given as a single weekly injection. Liraglutide, which is injected once a day, stimulates insulin production and can help with weight loss. However, the FDA is investigating a possible link to thyroid cancers.
When Insulin Might Be Needed
All non-insulin medications are used along with diet and exercise for diabetes. Various combinations of medications can be used, and your doctor will continue to monitor your condition for an effective treatment.
“Generally speaking, if you have tried several different combinations and have not been able to get your A1C below 7 percent, it’s time to move on to insulin,” says Pantalone.
For anyone diagnosed with type 2 diabetes, working with a team of specialists is the way to go. Your team should include a diabetes nurse educator and a nutritionist as well as your doctors. “Make sure you include an endocrinologist who specializes in diabetes on your treatment team,” Pantalone adds.
Finding the right diabetes medication for your current needs is an important step in your overall diabetes management. In addition to getting regular exercise and eating a good diabetes diet, work with your doctor to find a diabetes medication to lower your A1C levels and stay healthy.