Medication recommendations are changing rapidly. The usual strategy for beginning treatment of mild to moderate type 2 diabetes has been an initial trial of diet and exercise. These things remain of great importance but present-day thinking is that, unless they are completely successful, they should not be carried on very long before starting medications. Appropriate medications to get control of the diabetic condition as soon as possible appears most effective in the long run in producing good results long term and preventing diabetic complications.
Metformin is still the commonly accepted starting point for almost everybody. It is effective, low cost and has little serious toxicity. I like it because it directly addresses what appears to be the primary problem in type 2 diabetes, insulin resistance.
However, unless metformin, with diet and activity measures, is perfectly effective after 3 months or so, it's becoming standard recommended practice that one should consider adding one of the two new groups of diabetes medications, the GLP1 agents or the SGLT2 inhibitors (explanations of both of these coming). This is because both, when added on, not only reduce blood glucose but have also been found to produce significant reductions in major diabetes complications. As usual with new medications they are expensive and of course have their own side effects in some who use them.
GLP1 agents – We've discussed these previously. GLP1 is a hormone normally produced in the intestine that works when eating to decrease blood glucose and also to control the appetite. It is usually deficient in those with type 2 diabetes and seems to be an integral part of the diabetic problem. Multiple medications have now been developed which replace this action. Most patients, particularly those who are overweight, have significant improvement in blood glucose and lose some weight. But these medications have an additional important benefit in that several studies have now shown that they also reduce the risk of heart and vascular problems, a big issue with diabetes.
Those presently being sold are Victoza, Bydureon, Trulicity, Adlyxin and Ozempic, the last one seeming to be a little more effective than the others. All are given by injection once weekly except for Victoza which is injected daily. Most people tolerate them well but an occasional side effect is nausea.
A new development in this group is that within the last couple of months the FDA has approved an oral form of Ozempic (generic name – semaglutide), which seems to be just as effective as the injected form. It is taken daily and will be marketed under the name of Rybelsus. So those who want to avoid injections will have this alternative and I suspect it will be the way most will want to go.
SGLT2 inhibitors – These medications block the uptake of glucose by the kidney and cause a large output of glucose in the urine, in turn causing a lowering of glucose in the blood and some weight loss, and usually some lowering of the blood pressure. Due to the increased urine glucose there is some increase in urine output but usually not too bothersome, although the dose of other diuretic medications may have to be reduced. Also, because of the increased urine sugar, there is a problem in many women of vaginal yeast infections.
Those presently on the market are Invokana, Jardiance, and Farxiga. These are all taken orally and all of of them are also marketed in combination with metformin under different names.
The big news here is that these medications now have also been shown to significantly reduce heart problems as well as kidney complications. Most of the heart benefit has been shown to be primarily a reduction in the development of congestive heart failure (CHF), at present an increasing problem in the U.S. In fact, the improvement in CHF has now been shown to also be a benefit in non-diabetics, so that these are now being considered as an important new CHF treatment by cardiologists.
The finding that they also reduce the development and progression of kidney damage in diabetics has been a big pleasant surprise, and this benefit, along with the heart benefit is causing many experts to strongly recommend their use, particularly in those with some element of kidney involvement.
Sent from Mail for Windows 10
