Diabetes management has shifted away from a “one size fits all” model to a more individualized approach for each patient. Several important considerations including efficacy, cost, adverse effects, and potential benefits relevant to each patients’ needs will be examined throughout this blog.
It is now more important than ever to discuss your personal health goals with your provider as treatment options for type 2 diabetes are rapidly expanding with new evidence constantly emerging. One important recent change in practice, is we have found that some diabetes medications can decrease the risk of cardiovascular disease beyond that associated with improved blood sugar control. It is important to familiarize yourself with the different classes of medication and the advantages and points to consider for each treatment.
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| BIGUANIDES |
| Examples: metformin (Glucophage®), extended-release metformin (Glumetza®) |
| How they work: reduces the amount of sugar the liver produces and makes it easier for your body to use insulin |
| Advantages: |
| · Effective at lowering blood sugar |
| · Inexpensive and covered by most public and private plans |
| · Minimal impact on weight |
| · Used as a first choice for most Type 2 Diabetes patients |
| Points to mention: |
| · Stomach upset (gas, constipation, and diarrhea) are common side effects however this can be avoided if started at a lower dose and increased slowly. As well as taking this medication with food. |
| · Use with caution during illness or dehydration, speak to your healthcare provider regarding temporarily stopping the medication until illness improves. |
| · Dose adjustment (lowering) required if kidney function decreases |
| · May decrease Vitamin B12 absorption |
| DPP-4 INHIBITORS |
| Examples: linagliptin (Trajenta®), saxagliptin (Onglyza®), sitagliptin (Januvia®), alogliptin (Nesina®) |
| How they work: increases insulin after a meal to lower the blood sugar and decreases the amount of glucagon (a hormone that raises blood sugar) |
| Advantages: |
| · Very well tolerated with minimal side effects |
| · Effective at lowering blood sugar |
| · Minimal impact on weight (+/-) |
| · Easy once daily dosing, as a tablet |
| Points to mention: |
| · Caution if history of pancreatitis or pancreatic cancer |
| · Rare cases of severe joint pain |
| · May cause upper respiratory infection |
| · No added benefits beyond the blood sugar |
| · Coverage is dependent on the individual medication and funding source |
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| GLP-1 RECEPTOR AGONISTS |
| Examples: liraglutide (Victoza®), dulaglutide (Trulicity®), exenatide (Byetta®), semaglutide (Ozempic®, Rybelsus®), exenatide extended release (Bydureon®) |
| How they work: increases insulin after a meal to lower the blood sugar and decreases the amount of glucagon (a hormone that raises blood sugar) and slows emptying of the stomach |
| Advantages: |
| · Very effective at lowering blood sugar |
| · Promotes weight loss |
| · Added protective cardiovascular benefits |
| · Can be dosed once weekly or once-daily as an oral tablet |
| Points to mention: |
| · Available as an injection or oral tablet |
| · Use with caution if there is a history of pancreatitis or pancreatic cancer |
| · Main side effects include stomach upset which can decrease over time and with slower dose increases |
| · Coverage is dependent on the individual medication and funding source |
| SGLT-2 INHIBITORS |
| Examples: canagliflozin (Invokana®), dapagliflozin (Forxiga®), empagliflozin (Jardiance®) |
| How they work: reduces blood sugar by increasing the amount of glucose passed through the urine |
| Advantages: |
| · Very effective at lowering blood sugar |
| · Promotes weight loss |
| · Added protective cardiovascular and kidney benefits |
| · Taken orally as a tablet once daily |
| Points to mention: |
| · May cause yeast infections, urinary tract infections or low blood pressure |
| · Caution with a low carbohydrate diet |
| · Use with caution during illness or dehydration, speak to your healthcare provider regarding temporarily stopping the medication until illness improves. |
| · Coverage is dependent on the individual medication and funding source |
| INSULIN |
| Examples: |
| · long acting (basal) insulins: degludec (Tresiba®), detemir (Levemir®), glargine (Lantus®, Basaglar®, Toujeo®) |
| · intermediate-acting: Insulin neutral protamine Hagedorn – NPH (Humulin N®, Novolin ge NPH®) |
| · rapid-acting (bolus) insulin such as aspart (Novorapid®, Fiasp®, Trurapi®), glulisine (Apridra®), lispro (Admelog®, Humalog®) |
| · short-acting insulin such as regular insulin (Humulin R®, Novolin ge Toronto®); insulin human, biosynthetic (Entuzity®) |
| How they work: acts on insulin receptors, helping to replace the lack of insulin made by the body |
| Advantages: |
| · Very effective at lower blood sugar |
| · Flexible regimens available |
| · No maximum dose |
| Points to consider: |
| · Can cause weight gain |
| · It is an injectable that requires education around proper technique and blood glucose monitoring |
| · Risk of hypoglycemia – proper education around self-treatment is essential |
| · Coverage is dependent on the individual medication and funding source |
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| THIAZOLIDINEDIONES (TZDs) |
| Examples: pioglitazone (Actos®), rosiglitazone (Avandia®) |
| How they work: makes the body’s tissues more sensitive to insulin, so it can act more efficiently. Also, reduces the production of glucose from the liver. |
| Advantages: |
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| Points to mention: |
| · May cause weight gain |
| · May decrease bone density |
| · Can take up to 6-12 weeks for maximal effect |
| · Not advised to used in combination with insulin |
| · Increased risk of heart failure |
| · Coverage is dependent on the individual medication and funding source |
| SULFONYLUREAS |
| Examples: glimepiride (Amaryl®), glyburide (Diabeta®), gliclazide (Diamicron®) |
| How they work: stimulates the pancreas to product insulin throughout the whole day |
| Advantages: |
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| Points to mention: |
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| · Use with caution during illness or dehydration, speak to your healthcare provider regarding temporarily stopping the medication until illness improves |
| MEGLITINIDES |
| Example: repaglinide (Gluconorm®) |
| How it works: helps the pancreas make more insulin (short acting) |
| Advantages: |
| · After meal blood glucose targeted |
| · There is dosing flexibility i.e. if a meal is delayed or skipped, the dose can be adjusted accordingly |
| Points to consider: |
| · May cause low blood sugar (hypoglycemia), although less likely |
| · Must be taken with the first bite of every meal (may need to be taken up to three times a day) |
| · Coverage is dependent on the individual medication and funding source |
| ALPHA-GLUCOSIDASE INHIBITOR |
| Example: acarbose (Glucobay®) |
| How it works: slows down the digestion of carbohydrates in the gut so that sugar is absorbed into the blood more slowly |
| Advantages |
| · minimal risk of hypoglycemia |
| · minimal impact on weight |
| Points to consider: |
| · Gas and diarrhea are common but can decrease over time |
| · Must be taken with the first bite of every meal |
| · If hypoglycemia occurs, it must be treated with glucose tablets, milk or honey |
NOTE: The above tables do not include combination medications (oral and injectable).
There are pros and cons to every class of medication, therefore, it is important for each patient to have an individualized approach to their management that balances their priorities. With multiple choices available, we can now further tailor diabetes management to get to personalized health goals. As a result, it is important to customize and optimize treatment targets and therapy at regular intervals.
