Treatments for Type 2 Diabetes

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. See a separate leaflet called 'Type 2 Diabetes' for more general information about this condition.

How is the blood glucose level monitored?

The blood test that is mainly used to keep a check on your blood 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 last 2-3 months.

Treatment aims to lower you HbA1c to below a target level which is usually agreed between you and your doctor. The target level is usually somewhere between 6.5% and 7.5%. If your HbA1c is above your target level then you may be advised to 'step up' treatment to keep your blood glucose level down (for example, by increasing the dose of 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 reduce the level of your blood glucose (and HbA1c) if you:

• Eat a healthy balanced diet. A practice nurse and/or 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 fifteen 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
Metformin is a biguanide drug. It lowers blood glucose mainly by decreasing the amount of 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 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 to cause weight gain than some other glucose-lowering tablets. Another advantage of metformin is that it generally does not cause hypoglycaemia (low blood glucose level) 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.) You should not take metformin if your kidneys do not work properly.

Sulphonylurea drugs
There are several types of sulphonylurea drugs and include: glibenclamide, gliclazide, glimepiride, gliquidone, tolbutamide, 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, but not enough to keep the blood glucose level normal.)

A sulphonylurea tends to be used if you cannot take metformin ((perhaps because of side-effects or other reasons), or if you are not overweight. The one chosen may depend on duration of action, your age, side-effects, and whether your kidneys are working properly or not. 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 sulphonylurea in addition to other glucose-lowering tablets if one tablet does not control blood glucose well enough on its own.

Possible problems with sulphonylureas
As sulphonylureas 'boost' your level of insulin, hypoglycaemia (low blood sugar 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 common side-effect of sulphonylureas. Other side-effects are uncommon and are usually mild. They include: feeling sick, mild diarrhoea and constipation. (See the leaflet that comes in the drug packet for details.)

Thiazolidinediones (commonly called glitazones)
There are two types, pioglitazone and rosiglitazone. They lower blood glucose by increasing the sensitivity of you 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 sulphonylurea.

Possible problems with thiazolidinediones
There is slight risk of liver damage. Therefore, you should have a blood test to check on your liver function before starting these drugs. The blood test is then repeated every two months for the first year, and 'periodically' thereafter. Some weight gain is common side-effect, probably due to fluid retention. Hypoglycaemia is a possible, but uncommon, side-effect. Other possible side-effects are uncommon. (See the leaflet that comes in the drug packet for details.)

Nateglinide and repaglinide
These drugs and are not commonly used. They have a similar action to sulphonylureas. 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 sulphonylurea is generally preferred as a 'first choice' to boost the level of insulin throughout the day. As with sulphonylureas, possible side-effects include weight gain and hypoglycaemia. (See the leaflet that comes in the drug packet for details.)

• Nateglinide is licensed to be used in combination with metformin if metformin alone does not reduce the blood glucose enough.
• Repaglinide can be used alone, or in addition to metformin.

Acarbose
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 often.

Insulin

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. Sometimes it is used in addition to tablets (such as metformin or a sulphonylurea). 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 (low blood sugar) is a possible complication.

Other treatments

• To help prevent heart disease, stroke and poor circulation:
  • if you have high blood pressure then it should be treated. See separate leaflet called 'Diabetes and High Blood Pressure'.
  • you should not smoke.
  • you will usually be advised to take tablets to lower your blood cholesterol level.
  • you may be advised to take a daily aspirin.
• To help prevent some serious infections: you are usually advised to be immunised against 'flu each year, and have a one-off immunisation against the pneumococcus bacterium.
• Other treatments may be advised if you develop complications from diabetes.

Monitoring treatment

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 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.

© EMIS and PIP 2006   Updated: November 2006   PRODIGY Validated