The first-line treatment for type 2 diabetes is diet, weight control and physical activity. If your blood sugar (glucose) level remains high despite a trial of these lifestyle measures then tablets to reduce the blood glucose level are usually advised. Insulin injections are needed in some cases if the blood glucose level remains too high despite taking tablets. Treatments for other related problems may also be advised. This leaflet mainly discusses treatments that can lower the blood glucose level. It briefly mentions other treatments that may also be advised if you have type 2 diabetes.
How is the blood glucose level monitored?
The blood test that is mainly used to keep a check on your blood sugar (glucose) level is called the HbA1c test. This test is commonly done every 2-6 months by your doctor or nurse. The HbA1c test measures a part of the red blood cells. Glucose in the blood attaches to part of the red blood cells. This part can be measured and gives a good indication of your average blood glucose level over the previous 1-3 months.
Treatment aims to lower your HbA1c to below a target level which is usually agreed between you and your doctor. Ideally, the aim is to maintain your HbA1c to less than 48 mmol/mol (6.5%) but this may not always be possible to achieve and the target level of HbA1c should be agreed on an individual basis between you and your doctor (for example, by increasing the dose of your medication, etc).
In general, the nearer your HbA1c level is to normal:
- The better you are likely to feel, and
- The less likely you are to develop complications from diabetes, such as heart disease, eye problems, kidney problems, feet problems, etc.
Lifestyle - diet, weight control and physical activity
You can usually improve your sugar (glucose) control if you:
- Eat a healthy balanced diet. Your practice nurse and/or a dietician will give details on how to eat a healthy diet. The diet is the same as recommended for everyone. The idea that you need special foods if you have diabetes is a myth. Basically, you should aim to eat a diet low in fat, high in fibre and with plenty of starchy foods, fruit and vegetables.
- Lose weight if you are overweight. Getting to a perfect weight is unrealistic for many people. However, if you are obese or overweight then losing some weight will help to reduce your blood glucose level (and have other health benefits too).
- Do some physical activity regularly. If you are able, a minimum of 30 minutes' brisk walking at least five times a week is advised. Anything more vigorous and more often is even better. For example, swimming, cycling, jogging, dancing. Ideally you should do an activity that gets you at least mildly out of breath and mildly sweaty. You can spread the activity over the day - for example, two 15-minute spells per day of brisk walking, cycling, dancing, etc. Regular physical activity also reduces your risk of having a heart attack or stroke.
Many people with type 2 diabetes can reduce their blood glucose (and HbA1c) to a target level by the above measures. However, if the level remains too high after a trial of these measures for a few months then medication is usually advised. Medication is used in addition to, and not instead of, the above lifestyle measures.
Medication to reduce the blood glucose level
Metformin is a biguanide medicine. It lowers blood glucose mainly by decreasing the amount of sugar (glucose) that your liver releases into the bloodstream. It also increases the sensitivity of your body's cells to insulin (so more glucose is taken into cells with the same amount of insulin in the bloodstream.) Metformin has also been shown in studies to lower your risk of other complications of diabetes (such as heart attack and stroke).
Metformin is commonly the first tablet advised if your blood glucose level is not controlled by lifestyle measures alone. It is particularly useful if you are overweight, as it is less likely than some other glucose-lowering tablets to cause weight gain. Another advantage of metformin is that it generally does not cause a low blood glucose level (hypoglycaemia - sometimes called a 'hypo') which is a possible problem with some other glucose-lowering tablets. You can also take metformin in addition to other glucose-lowering tablets if one tablet does not control blood glucose well enough on its own.
Possible problems with metformin
When metformin is first started, some people feel sick or have mild diarrhoea. These are less likely to occur if you start with a low dose and gradually build up to the usual dose over a few weeks. If these side-effects do occur, they tend to ease off in time. Other side-effects are uncommon. (See the leaflet that comes in the drug packet for full details of cautions and possible side-effects.)
There are several types of sulfonylurea medicines. These include gliclazide, glimepiride, and glipizide. They work by increasing the amount of insulin that your pancreas makes. (If you have type 2 diabetes, you still make insulin in your pancreas. However, you do not make enough to keep your blood glucose level normal.)
A sulfonylurea tends to be used if you cannot take metformin (perhaps because of side-effects or other reasons), or if you are not overweight. Usually a low dose is started. The dose can be increased if necessary every few weeks until there is good control of the blood glucose level. You can take a sulfonylurea in addition to other glucose-lowering tablets if one tablet does not control blood glucose well enough on its own.
Possible problems with sulfonylureas
As sulfonylureas boost your level of insulin, low blood sugar (hypoglycaemia, or hypo) is a possible complication. However, this is an uncommon problem and unlikely to happen if you: have regular meals, don't miss meals, and don't drink too much alcohol. Symptoms of hypoglycaemia include trembling, sweating, anxiety, blurred vision, tingling lips, paleness, mood change, vagueness or confusion. To treat hypoglycaemia: take a sugary drink or some sweets. Then, eat a starchy snack such as a sandwich.
Some weight gain is a common side-effect. Other side-effects are uncommon and are usually mild. They include: feeling sick (nausea), mild diarrhoea and constipation. (See the leaflet that comes in the medicine packet for full details of cautions and possible side-effects.)
Nateglinide and repaglinide
Nateglinide and repaglinide have a similar action to sulfonylureas. However, they are not commonly used. After taking a dose they quickly boost the insulin level, but the effect of each dose does not last very long. Each dose is taken shortly before main meals (and a dose omitted if you miss a meal). One of these drugs may be an option if you have meals at irregular times. However, a sulfonylurea is generally preferred as a first choice to boost the level of insulin throughout the day. As with sulfonylureas, possible side-effects include weight gain and hypoglycaemia. (See the leaflet that comes in the medicine packet for full details of cautions and possible side-effects.)
Dipeptidyl peptidase 4 inhibitors (also known as incretin enhancers)
This group includes linagliptin, saxagliptin, sitagliptin and vildagliptin. Dipeptidyl peptidase-4 (DPP4) is a chemical (an enzyme) which breaks down hormones called incretins. Incretins are chemicals (hormones) which are produced by the gut (intestine) in response to food. These medicines work by reducing your blood glucose level by enhancing the effects of incretins as they prevent DPP4 from working. One of these may be advised in addition to metformin or a sulfonylurea, or even to both of these if your HbA1c level is still high.
Side-effects are uncommon and are usually mild. They may include feeling sick or having wind (flatulence). If you take vildagliptin then there is a slight risk of liver damage. Therefore, you should have a blood test to check on your liver function before starting it and then at regular intervals. (See the leaflet that comes in the medicine packet for full details of cautions and possible side-effects.)
Commonly called glitazones (eg, pioglitazone), thiazolidinediones lower blood glucose by increasing the sensitivity of your body's cells to insulin (so more glucose is taken into cells for the same amount of insulin in the bloodstream). They are not usually used alone, but are an option to take in addition to metformin or a sulfonylurea.
Possible problems with thiazolidinediones
You should not take these medicines if you have heart failure, as this can worsen. There is also a slight risk of liver damage. Therefore, you should have a blood test to check on your liver function before starting these medicines. The blood test is then repeated at regular intervals. Some weight gain is a common side-effect, probably due to fluid retention. Hypoglycaemia is an uncommon side-effect. Other possible side-effects are uncommon. (See the leaflet that comes in the medicine packet for full details of cautions and possible side-effects.)
Acarbose works by delaying the absorption of carbohydrates (which are broken down into glucose) from the gut. Therefore, it can reduce the peaks of blood glucose which may occur after meals. It is an option if you are unable to use other tablets to keep your blood glucose level down. It can also be used in addition to other glucose-lowering tablets. However, many people develop gut-related side-effects when taking acarbose, such as bloating, wind, and diarrhoea. Therefore, it is not used very often.
Insulin injections lower blood glucose. Only some people with type 2 diabetes need insulin. It may be advised if your blood glucose level is not well controlled by tablets. The dose and type of insulin used varies from person to person. Sometimes insulin is used alone. However, sometimes it is used in addition to your tablets (such as metformin or a sulfonylurea). If you are advised to use insulin your doctor or practice nurse will give detailed advice on how and when to use it.
Possible problems with insulin
Some weight gain is a common side-effect. Weight gain may be less of a problem if you use insulin in combination with a glucose-lowering tablet such as metformin. Hypoglycaemia is a possible complication.
Exenatide and liraglutide - glucagon-like peptide-1 mimetics
Exenatide and liraglutide are treatments given as an injection. They work in a similar way to the action of the naturally occurring hormone glucagon-like peptide-1 (GLP-1). These actions include stimulating insulin secretion in response to glucose and preventing glucagon (a hormone which raises blood sugar) release after meals.
Exenatide and liraglutide are usually used as an add-on treatment to improve glucose control when insulin treatment is not acceptable. There is a once weekly treatment available. Side-effects may include hypoglycaemia, feeling sick and headaches. People receiving this treatment usually lose weight.
- To help prevent heart disease, stroke and poor circulation:
- To help prevent some serious infections, you are usually advised to be immunised against flu each year, and also given an immunisation against pneumococcal infection.
- Other treatments may be advised if you develop complications from diabetes.
Your treatment should be monitored regularly in a diabetes clinic. You may need to step up treatment from time to time. For example, your blood sugar (glucose) may be well controlled by lifestyle measures alone for a number of years. However, in time, you may need to add in one tablet. And then at a later time you may need to add in another tablet to keep your blood glucose level down.
Further help & information
Dr Tim Kenny
Dr Colin Tidy
Dr John Cox