We have discussed in our previous blogs as well as our topic on type 2 diabetes about the factors we consider when recommending treatment options for type 2 diabetes. Today by summarizing what we have previously discussed, we will provide you with the rationales behind what our endocrinologist recommends for the management of type 2 diabetes.
What we want to avoid while lowering our blood glucose:
- Putting more pressure on the pancreas
- Gaining weight
- Hypoglycemia (low blood sugar)
- Other major side-effects
Therefore, we DO NOT recommend the following:
- Sulfonylureas – works by putting pressure on the pancreas to produce more insulin, causes hypoglyemia, and weight gain
- Meglitinides – similar to sulfonylurea, only short acting. Puts pressure on the pancreas, causes hypoglycemia and weight gain.
- Thiazolidinediones – not recommended because of their association to major side-effects related to the liver and heart. We have too many options nowadays to choose from than risking these potentially dangerous side-effects
- Insulins – Insulin takes pressure off the pancreas, but unless you can adjust your insulin doses optimally, insulin therapy will cause hypoglycemia and weight gain. Also most type 2 diabetes do not want to be burdened with managing insulin injections several times a day when they have the choice of managing their diabetes with oral medications.
What we want to achieve in managing type 2 diabetes:
- Take pressure off the pancreas
- Lose weight
- Improve insulin sensitivity
- Protect our arteries, kidney and heart
The followings are what we would recommend in sequence:
- Diet modifications – eating a healthy diet in smaller portions takes pressure off the pancreas, helps weight loss, and is good for our arteries, heart and kidney and overall health. No amount of medication can achieve this.
- Exercise and lose weight – Exercise and weight loss will improve our body’s insulin sensitivity and reverse type 2 diabetes.
- Metformin – improves insulin sensitivity, weight neutral, does not cause hypoglycemia, has a long track-record for effectiveness and safety, and is inexpensive. The most cost/effective drug option. Usually recommended as the first-line therapy.
- DPP4-Inhibitor (Januvia/Onglyza/Tradjenta) – improves GLP1 level, which improves insulin sensitivity, takes pressure off the pancreas, weight neutral, tend to improve cholesterol levels, recent studies showed that it may be beneficial for the heart. We recommend adding this when metformin alone does not achieve ideal control.
- SGLT2 Inhibitor (Jardiance) – the newest class of diabetes medication. Expels excessive blood sugar through urine and as a result helps weight loss. Studies also found Jardiance has a lot of benefits for heart conditions and slows down the progression of kidney disease in diabetes. Recently, the FDA officially accepted the benefits of Jardiance in heart conditions. We recommend adding SGLT2 Inhibitors on top of metformin and DPP-4 inhibitors or as a first-line treatment in diabetes patients who also have heart conditions.
- Alpha-glucosidase Inhibitors (Acarbose) – this works only in your intestines so you don’t absorb the carbs you eat and expel them, which often causes diarrhea. The same can be actually achieved by diet modification. If you can stick to a low-carb diet, you can skip this drug and diarrhea.
- GLP1 Agonist (Victoza) – Very similar effects to DPP-4 inhibitors, which works by increasing GLP1 levels. The reason we do not recommend these is only due to inconvenience and price – they only come in injections and are usually pricier than DPP-4 Inhibitors.
To summarize our recommendations in managing type 2 diabetes:
- Start with Diet + Exercise + Metformin (+ consider Jardiance if patient has heart failure)
- + a DPP-4 Inhibitor (Januvia or Onglyza or Tradjenta)
- + a SGLT2 Inhibitor (Jardiance)
- +/- a Alpha-glucosidase Inhibitor if can not maintain a low-carb diet. (Acarbose)
- +/- a GLP1 Agonist depending on financial status and willingness to use injection
- Add insulin if blood glucose is not controlled despite using everything above
- Avoid medications from the Sulfonylurea, Meglitinide, and Thiazolidinedione families.
Please be advised that these recommendations are based on the assumption that the patient does not have any other major medical conditions. Some medications need to be avoided in pregnancy and in patients with severely compromised liver and kidney functions. Talk to your health care provider or consult our licensed pharmacists for free.
You can also purchase DPP4 Inhibitors (Januvia, Onglyza, Tradjenta), SGLT2 Inhibitors (Jardiance, Invokana) and combination medications such as Janumet (metormin + Januvia) from our online store. Do not hesitate to call and consult our pharmacists regarding your medication needs at any time.