Type 2 Diabetes Medicines: What You Need to Know

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1 Type 2 Diabetes Medicines: What You Need to Know Managing diabetes is complex because many hormones and body processes are at work controlling blood sugar (glucose). Medicines for diabetes include oral medicines (pills) and medicines like insulin, which must be injected. Your healthcare provider will work with you to determine which types of diabetes medicines will be best for you. This handout tells you about each medicine and how it works in your body to lower blood glucose. Overview Diabetes medicines work in different ways and are usually chosen by how they work in the body (making more insulin or helping the body use insulin better), and by their side effects. People with type 2 diabetes can usually use oral medicines (pills) to help keep their blood glucose levels in a healthy range. But, there is no magic pill when it comes to diabetes. You may have to try more than one to see what works best for you. Pills work best when added to a healthy diet and exercise plan. And, they re only available by prescription. Diabetes pills are most effective for people who have had diabetes for less than 10 years and take less than 20 units of insulin per day, according to the American Diabetes Association. Also, women who are pregnant or plan to become pregnant will need to manage their blood glucose levels through a combination of diet, exercise, and possibly insulin, as diabetes pills are not safe for pregnant women. Oral Medicines There are several types of diabetes pills: Sulfonylureas: These are older diabetes drugs that work to help the pancreas make more insulin; insulin helps to lower blood glucose. They re usually taken one or two times per day. Diabinese is an older form of sulfonylurea, while Glucotrol and Glucotrol XL, Micronase, Glynase, DiaBeta, and Amaryl are all examples of newer sulfonylureas. This type of medicine can cause the blood glucose to go too low. It can also cause weight gain. But, they are very low-cost medications and can often be purchased through the $4.00 plans at many pharmacies. Biguanides: These work by decreasing the amount of glucose made by the liver and by improving the way that insulin works in your muscles. They re usually taken twice a day. The best-known of these drugs is metformin, which is commonly the first medication used in diabetes treatment. Your healthcare provider will need to be sure your liver and kidneys are working well in order for you to take this medicine. This medication, if not combined with others, won t make your blood glucose go too low. It also doesn t lead to weight gain in most people. It is a low-cost medication and available through many $4.00 drug plans.

2 Meglitinides: Like sulfonylureas, these drugs help the pancreas make more insulin but they do it very rapidly and for a short length of time. For this reason, they are taken three times a day, before meals. Examples include Prandin and Starlix. This medication is very short acting, so if you often skip meals, you can skip this medication as well and lower your risk for low blood glucose. It is a more expensive medication and is not available on most $4.00 drug plans. Thiazolidinediones: These drugs work in two ways. They help insulin work better in muscle and fat tissue, leading to increased use of glucose from the blood to the cells and lowering blood glucose. They also decrease the amount of glucose the liver produces. Avandia and Actos are examples of thiazolidinediones. This class of medications can also cause weight gain and swelling, especially in the feet and legs. In rare cases it can cause damage to the liver so, to be safe, your healthcare provider should do a blood test to check your liver while taking this drug. If the liver numbers go up, the drug may need to be stopped. This type of medication is expensive. DPP-4 inhibitors: These drugs work by stopping the breakdown of a naturally occurring substance in the body called GLP-1, a chemical that helps to lower blood glucose. DPP-4 inhibitors slow down the breakdown of GLP-1 so the GLP-1 lasts longer, helping to lower blood glucose. DPP-4 inhibitors help your pancreas make more insulin insulin helps to lower blood glucose. They also help to decrease the amount of glucose made by the liver. This is a newer class of medications and doesn t lower blood glucose as much as some of the other medicines. Examples include Januvia, Onglyza, Tradjenta, and Nesina. This medication, on its own, doesn t usually cause low blood glucose or weight gain. It is a newer medication and costs about $8.00 per day if you are paying cash. SGLT2 inhibitors: In people with type 2 diabetes, the kidneys can hold on to glucose, which can cause blood glucose levels to increase. SGLT2 inhibitors stop glucose from being reabsorbed into the kidneys, allowing the blood glucose to be sent out from the body in urine. Invokana is the first SGLT2 inhibitor to be approved for use in the U.S. This is one of the newest kinds of diabetes medications and also doesn t lower blood glucose as much as some of the older ones. More glucose in the urine raises the risk of urinary tract infections (UTIs), but extra fluid intake and good hygiene can help reduce this risk. On its own it doesn t usually cause weight gain or low blood glucose. It also costs about $8.00 per day if you are paying cash. Alpha-glucosidase inhibitors: These medications lower blood glucose by slowing down the breakdown of starches (such as bread and potatoes) and certain types of sugar (such as table sugar) from the food in your intestines (gut), slowing the rise of blood glucose in the bloodstream after a meal. Basically, these medicines send some of the starches you eat through your body without being absorbed. These medicines are taken with the first bite of each meal. Precose and Glyset are examples of alpha-glucosidase inhibitors. These medications typically cause a lot of gas (farting) when you first start taking them, but it usually goes away after you are on them for a while. This class of medications has been around for over 15 years but hasn t been used a lot. They don t cause weight gain and, alone, don t cause low blood glucose. They are still rather expensive and don t lower blood glucose as much as some of the older medications.

3 Bile acid sequestrants: Welchol is a bile acid sequestrant, which is primarily a cholesterol-lowering medication. But it also lowers blood glucose in a way that is not well understood. What is known is that bile acid sequestrants bind to bile acids in the digestive system. The body responds by using cholesterol to replace the bile acids, which lowers cholesterol levels. High cholesterol levels are associated with high blood glucose. Bile acid sequestrants are often the medication of choice for people who can t tolerate other types of diabetes medications because of liver problems. Because bile acid sequestrants aren t absorbed into the bloodstream, they don t affect the liver. Combination therapy: Sometimes more than one diabetes medication is needed to get blood glucose levels into healthy ranges. When this is the case, your healthcare provider may prescribe, for example, a sulfonylurea along with a biguanide. Or, your health care provider may prescribe a combination drug for you a medication made up of two separate drugs, such as a combination of a DPP-4 inhibitor with metformin. Injectable Medications Amylin mimetic (pramlintide): This medicine mimics the hormone amylin, which is normally made in the pancreas. While insulin regulates the removal of blood glucose from the bloodstream, amylin regulates the amount of glucose going into the bloodstream. It helps to decrease the amount of glucose made by your liver; it slows down the breakdown of foods in your stomach and intestines; this slows down increases in blood glucose. It also decreases appetite, and users of pramlintide usually lose an average of more than 6 lbs. in the first 6 months of use, mainly by eating smaller portions at meals and snacking less often. Pramlintide s effects last for only about 3 hours, so it needs to be injected at just about every meal to work throughout the day. It is slightly acidic, so it stings a little when injected. This is also why you can t mix it directly with insulin in a syringe or other injection device. The most common side effect is mild nausea that may occur minutes after an injection. But, this usually fades or disappears after a few weeks. And, because pramlintide slows digestion so much, hypoglycemia can be a problem. You often have to lower your dose of mealtime insulin to prevent hypoglycemia. It takes a little effort to use this drug, but once you learn it, this medicine can be a good tool to control post-meal blood glucose levels and curb hunger. GLP-1 agonists: When foods come in contact with the inner lining of the small intestine, special chemicals are released. One of these is called glucagon-like peptide-1 or GLP-1. GLP-1 suppresses glucagon production, slows digestion, and decreases appetite to decrease blood glucose ups and downs and lose weight. GLP-1 also helps the pancreas release a burst of insulin following a meal, when blood glucose levels are typically higher. Insulin helps to lower blood glucose. GLP-1 agonists mimic the effects of GLP-1. Currently, there are 4 injectable drugs of this type available: exenatide (Byetta), taken twice daily; liraglutide (Victoza), taken once daily; extended-release exenatide (Bydureon), taken once a week, and albiglutide (Tanzeum), which is also once weekly dosing. Regular exenatide, liraglutide, and albigutide are injected with a pen device, while extended-release exenatide is injected with a syringe. GLP-1 agonists are approved to be used alone, or in combination with oral diabetes drugs or basal insulin for the treatment of type 2 diabetes. The main side effect of GLP-1 agonists is mild

4 nausea during the first few weeks of use. Newly approved albiglutide also has adverse effects of diarrhea and injection site reaction; it is not prescribed if there is a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia. These drugs work very well for some people, but provide little benefit for others. You can t know in advance whether these drugs will work for you. Insulin: Insulin is a hormone in the body made by the pancreas. It helps to decrease the amount of glucose made by the liver, and helps to move glucose out to the blood stream and into the muscles and fat where the glucose is used for energy. It works like a key opening a door for blood glucose to go through. People with type 1 diabetes must use injectable insulin to replace the insulin made naturally by your body. Many people with type 2 diabetes use insulin as well, especially when diabetes medicines (pills) don t control blood glucose well enough. Insulin must be injected because, if taken by mouth, it would break down in the stomach and therefore would not work. There are several types of insulin. Each type works differently. They may work slowly or quickly; last a different length of time; and have a different peak period of strength. There are several strengths of insulin available, but the most common is U-100, which means it has 100 units of insulin per milliliter of fluid. The basic types of insulin are: Rapid-acting insulin: This type of insulin starts working in about 15 minutes, peaks in about an hour, and continues working for 2 to 4 hours after injection. Examples include Apidra, Humalog, and NovoLog. Regular (short-acting) insulin: This type of insulin starts working in about 30 minutes, peaks in about 2 to 3 hours, and is effective for 3 to 6 hours after injection. Examples include Humilin R and Novolin R. Intermediate-acting insulin: This type of insulin starts working in 2 to 4 hours, peaks in about 4 to 12 hours, and is effective for about 18 hours after injection. Examples include Humilin N and Novolin N. Long-acting insulin: This type of insulin starts working several hours after injection and lowers blood glucose at a fairly even pace for 24 hours. Examples include Levemir and Lantus. Combination insulin therapy: Sometimes more than one type of insulin is used to get blood glucose levels under control. This is often the case when one type of insulin isn t lowering blood glucose levels enough. Insulin can be injected using a syringe and a bottle of insulin, but there are other options. Insulin pens are common. These use a dial to determine how much insulin is in the injection. Another option is the insulin pump. It uses a small tube, or catheter, placed under the skin (usually in the abdomen) and delivers a steady dose of insulin throughout the day. The user sets the amount of insulin the pump delivers and can adjust the amount as needed. Sources: American Diabetes Association. Scheiner, G. (January/February, 2014). Beyond insulin: What else might help? Diabetes Self Management,

5 Benefits AI.pdf 1 6/4/14 12:50 PM Promoting health through patient education Type of Medicine Generic Name Brand Name Biguanides Block the liver from making sugar Metformin Glucophage Lowers A1C by about 1 point Lowers bad cholesterol more than other types Sulfonylureas Raise the amount of insulin in the body Glimepiride Amaryl Lowers A1C by about 1 point Glipizide Glucotrol Glyburide Diabeta Glynase Prestab Micronase Meglitinides Raise the amount of insulin in the body Repaglinide Prandin Lowers A1C by about 1 point Nateglinide Starlix Thiazolidinediones (TZDs) Help the body use insulin better Pioglitazone Actos Lowers A1C by about 1 point Lowers triglycerides (a kind of fat in your blood) more than other types Might protect kidney function Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Raise the amount of insulin in the body after a meal Sitagliptin Januvia Lowers A1C by less than 1 point Saxagliptin Onglyza Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists Raise the amount of insulin in the body Exenatide Byetta Less weight gain than other medicines Liraglutide Victoza Less is known about how well this medicine lowers A1C compared with other medicines Albiglutide Tanzeum Combinations Glyburide/metformin Metformin/pioglitazone Metformin/sitagliptin Metformin/saxagliptin Metformin + GLP-1 receptor agonists Metoformin + basal insulin Metformin + premixed insulin Source: Agency for Healthcare Research and Quality (AHRQ.gov), Lowers A1C by about 2 points Metformin/pioglitazone lowers triglycerides Metformin + GLP-1 receptor agonists may cause less weight gain than other combinations of medicines Some of the combinations of medicine may come in a single pill, and are shown with a / symbol between them. Others are taken together but are separate medicines, and are shown with a + symbol.

6 Side Effects AI.pdf 1 6/4/14 12:44 PM Promoting health through patient education Type of Medicine Generic Name Brand Name Biguanides Metformin Glucophage Some risk for low blood sugar Less weight gain than other medicines Higher risk for stomach problems (gas, diarrhea) Sulfonylureas Glimepiride Amaryl May cause weight gain Glipizide Glucotrol 3 to 5 times more likely to cause low blood sugar Glyburide Diabeta May cause stomach problems Glynase Prestab Micronase Meglitinides Repaglinide Prandin May cause weight gain Nateglinide Starlix Risk for low blood sugar Thiazolidinediones (TZDs) * Pioglitazone Actos May cause weight gain Some risk for low blood sugar Can add to risk of heart failure or make it worse Increases the risk for fracture, especially in women May cause bladder cancer when used longer than 1 year Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Sitagliptin Januvia Saxagliptin Onglyza Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists Exenatide Byetta Liraglutide Victoza Albiglutide Tanzeum Combinations Glyburide/metformin Metformin/pioglitazone Metformin/sitagliptin Metformin/saxagliptin Metformin + GLP-1 receptor agonists Metformin + basal insulin Metformin + premixed insulin these medicines these medicines Some combinations with drugs such as sulfonylureas may increase the risk of low blood sugar Pioglitazone combinations may cause more weight gain than other medicines Pioglitazone combinations can add to the risk of hip and non-hip fractures, especially for women Some combinations with metformin increase the risk of stomach problems, but not as much as metformin alone *NOTE: The U.S. Food and Drug Administration has issued an alert that TZDs (pioglitazone or rosiglitazone) should not be taken by patients with serious or severe heart failure. Rosiglitazone also increases the risk for heart attack and stroke. According to the FDA, rosiglitazone is to be used only if other drugs do not work to lower your blood sugar. Talk with your healthcare provider. Source: Agency for Healthcare Research and Quality (AHRQ.gov), 2011.