Recall of metformin extended releaseIn May 2020, the Food and Drug Administration (FDA) recommended that some makers of metformin extended release remove some of their tablets from the U.S. market. This is because an unacceptable level of a probable carcinogen (cancer-causing agent) was found in some extended-release metformin tablets. If you currently take this drug, call your healthcare provider. They will advise whether you should continue to take your medication or if you need a new prescription.

1. What factors does my doctor consider when recommending a treatment for type 2 diabetes?

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
  • the risk of low blood sugar with any particular therapy option
  • potential side effects of treatment
  • body weight and the potential for the treatment to affect body 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 past three 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 single 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.

The goal of your treatment is to lower your A1C below 7 percent. This target is set by the American Diabetes Association guidelines. If an individual’s A1C is over 9 percent, it’s common for two medications to be started 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.

2. When it comes to non-insulin medications that treat type 2 diabetes, there are a lot of options — how are these medications different from one another?

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.

Sulphonylurea

Medications in this class include glipizide, glyburide, and glimepiride. These medications are 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, also called GLP-1

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. 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, also called DPP-4 inhibitors

There are several medications available in this class. They’re all brand-name drugs, including Januvia, Onglyza, Tradjenta, and Galvus. 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 post-meal blood sugar levels.

Alpha-glucosidase inhibitor

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

Sodium-glucose cotransporter-2 inhibitors, also called SGLT-2 inhibitors

This is the newest class of diabetes medications. They lower blood glucose levels by removing glucose from the body via urine. There’s growing evidence that this class provides cardiovascular benefits, apart from the benefits of improved blood glucose management. Medications in this class are all brand name, including Jardiance, Farxiga, Invokana, and Steglatro.

3. Why do some people with type 2 diabetes need to take insulin while others don’t?

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 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.

4. If I make lifestyle changes, is it possible that my treatment needs for type 2 diabetes might change, too?

Lifestyle changes 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 change their diet, lose weight, and increase and maintain their 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 changing their lifestyle habits. Never stop taking a medication without speaking to you doctor first.

5. If I’m taking medication for another condition, could that affect which type 2 diabetes medication I should take?

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

Many different 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.

6. Are there any symptoms I might experience if my treatment isn’t working effectively? What should I watch out for?

If the 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 her spare time, Dr. Basina enjoys hiking and reading.