Written by: Kenzie Provencher, Dietetic Intern
There are so many different medications for the management of diabetes it can be hard to understand where all the recommendations come from, and why your doctor has recommended one medication over another. In this blog we’ll dive into a brief explanation of some of the considerations for choosing a medication for diabetes, but it’s important to remember that your treatment regimen is specific to you. If you have any questions about your specific medications, consult with your team for more support.
First Line Therapy:
The first line therapy generally includes metformin and lifestyle modifications. Let’s dive into understanding the first line of medications: Metformin (or glucophage).
Metformin acts on three main areas of the body in order to lower blood glucose. First, metformin lowers blood glucose by decreasing the amount of glucose the liver releases into the blood. Metformin also helps body cells respond to insulin more effectively so those cells can let more glucose inside. Lastly, metformin slows how quickly glucose moves from your intestines into your blood after meals. It even stops your body from absorbing some of the sugar from your meals. Because of the ways it works in the GI tract, metformin should be taken 1-2 times a day with your morning and/or evening meals.
According to the Standards of Medical Care in Diabetes 2022, metformin is highly effective for lowering A1c, and it does not cause hypoglycemia (low blood sugar). Studies have shown that it might cause modest weight loss, and that it might benefit atherosclerotic cardiovascular disease.1 Metformin is taken in pill form, and it’s generally low cost. Common side effects include gastrointestinal distress like diarrhea and nausea, as well as possible B12 deficiency. Make sure you speak to your doctor about any side effects you may be experiencing.
Considerations for adding additional medications:
The next steps in diabetes management are completely individualized! They are made with careful consideration from your doctor about your diabetes and other health history. However, here are some questions to ask when considering the right medication to add to your metformin treatment:
How effective is this medication at lowering A1c?
Does this medication have any weight change side effects?
Does this medication cause hypoglycemia (low blood sugar)?
How expensive is this medication? Can I afford any co-pays associated with this medication?
Does this medication also have the potential to reduce the risk of cardiovascular disease?
Reviewing the Options:
The next medications we often see prescribed for our clients are SGLT2 inhibitors and GLP-1 Receptor Agonists. These are a fairly new class of medications which have shown promising positive effects on cardiovascular disease risk reduction!
GLP-1 Receptor Agonists
GLP-1 Receptor Agonists work to lower blood glucose in many ways. First, they help slow stomach emptying, so food stays in your stomach longer and the glucose is absorbed into the bloodstream at a slower rate. Second, they tell the pancreas to reduce the amount of glucagon it releases. Since glucagon tells the liver to send more glucose into the bloodstream, reducing the amount of glucagon helps reduce the amount of glucose in the blood after meals. Next, GLP-1 RA helps the pancreas release insulin during meals so cells can (hopefully) absorb glucose from the meal. Lastly, GLP-1 signals the brain to say “I’m full,” so we know when it’s time to stop eating.
GLP-1 RAs have been shown to be highly effective at lowering A1c levels, and they have not been shown to cause hypoglycemia. Studies have shown that they have a moderate weight loss effect. Certain brands of GLP-1 RAs have been found to help reduce the risk of cardiovascular disease and lower blood pressure and cholesterol levels. Other considerations for use include that they are typically expensive, and most brands have to be injected, although one is available in pill form. Of note, the medication may come with some gastrointestinal side effects (nausea, vomiting, diarrhea).
SGLT2 Inhibitors work to lower blood glucose in a completely different way. SGLT2 inhibitors signal your kidneys to filter glucose out of your blood and into your urine. In this method the glucose is urinated out rather than staying in the blood or being absorbed into cells.
Studies have shown SGLT2 Inhibitors to be an efficacious option, lowering A1C 0.6- 1.2% (2)SGLT2 Inhibitors have been shown to have only intermediate effectiveness on lower A1c. They do not cause hypoglycemia, and they have the potential to cause weight loss. Certain brands have been shown to help reduce the risk of cardiovascular disease, lower blood pressure, lower the risk of heart failure, and lower the risk of kidney disease progression. Urinary tract infections and yeast infections have been noted as common side effects.
We have just scratched the surface of the many different medications available to support you through your diabetes treatment. Please reach out to your health care professionals if you have additional questions!
American Diabetes Association Professional Practice Committee; 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S125–S143. https://doi.org/10.2337/dc22-S009
Bashier, A., Khalifa, A. A., Rashid, F., Abdelgadir, E. I., Al Qaysi, A. A., Ali, R., Eltinay, A., Nafach, J., Alsayyah, F., & Alawadi, F. (2017). Efficacy and Safety of SGLT2 Inhibitors in Reducing Glycated Hemoglobin and Weight in Emirati Patients With Type 2 Diabetes. Journal of clinical medicine research, 9(6), 499–507. https://doi.org/10.14740/jocmr2976w