What are the 10 best drugs to treat diabetes?
We will now go through 10 best drugs for the treatment of diabetes, both tablets and injections – starting with metformin, one of the oldest, but still used today. They are all used in type 2 diabetes, and some in type 1 diabetes as well.
There are two types of diabetes. Patients with type 1 diabetes have absolute insulin deficiency. Those with type 2 diabetes have insulin resistance; later they can have reduced insulin secretion insulin deficiency. Therefore, drugs mainly acting in type 2 diabetes reduce insulin resistance and enhance insulin production.
Let’s now go through the 10 best drugs for diabetes.
1.Metformin – biguanide
If you have type 2 diabetes, metformin is usually the first diabetes tablet your doctor will prescribe; if lifestyle changes alone, like a healthy diet and physical activity, are not enough to manage your blood sugar levels. It acts mainly by reducing insulin resistance in the liver, muscles, and fat cells.
Metformin has very good safety profile. Nausea and poor appetite are the main side effects. They should not be started (or need to stopped) at later stages of kidney failure (CKD3B and higher). There are two types of metformin: standard and slow release. The slow-release preparation has less gastrointestinal side effects.
Sulphonylureas
2.1. Tolbutamide (or chlorpropamide) – first generation sulphonylurea
2.2. Gliclazide (or glimepiride, glipizide and glibenclamide) – second generation sulphonylurea
There are several different tablets in this group. They work mainly by stimulating cells in the pancreas to make more insulin. This action is dependent upon functioning beta (ß) cells in the pancreatic islets. They also help insulin to work more effectively in the body.
Gliclazide and glimepiride are the most commonly used ones. This group of medications are generally safe to use but there is a risk of hypoglycaemia with the longer acting preparation (tolbutamide and glibenclamide), which are seldomly used now.
They can induce weight gain.
3. Repaglinide (or nateglinide and meglitinide) – prandial glucose regulators
You should take these medications about half an hour before meals, up to three times a day. They are similar to sulphonylureas but work faster to stimulate insulin production from the pancreas, and do not last as long.
If you miss a meal, do not take them. In that situation, they can cause low a blood sugar level, which is called hypoglycaemia.
4. Acarbose – alpha-glucosidase inhibitor
This tablet belongs to a group of medications called alpha-glucosidase inhibitors. This tablet slows down starchy food absorption after a meal. This means your blood sugar levels will not rise as fast. It is used especially in reactive hypoglycaemia in diabetes.
5. Pioglitazone (or rosiglitazone) – thiazolidinediones (TZDs; or ‘glitazones’)
They belong to a family of medications called thiazolidinediones (or ‘glitazones’). They help your body use natural insulin better, and protect the cells in the pancreas – so you can produce insulin for longer. They are usually taken once or twice a day with or without food. You may experience ankle swelling with this medication, otherwise they are generally safe.
6. Dapagliflozin (or empagliflozin and canagliflozin) – SGLT2 inhibitors
These medications increase the amount of sugar passed in urine. In this way, they reduce blood sugar levels.
They also remove sodium and water from the body, which makes them useful for chronic kidney disease (CKD) and chronic heart failure (CHF; usually due to IHD). Patients with diabetes often have CKD and IHD. They are well tolerated.
But an increase in urinary sugar can make you prone to urinary tract infections (UTIs) and thrush. If happens you need to stop the medication, after discussion with your doctor. You need to take this tablet once a day, with or without food.
If you are on this medication, and have an acute severe illness, you need to stop it temporarily; as SGT2is can cause an increase keto acids in your body (leading to something called diabetic ketoacidosis, DKA). This is called a ‘sick day rule’. Talk to your doctor about when to restart them.
Note. Your urine will test positive for sugar because of the way they work.
7. Liraglutide (once-daily injection) – or dulaglutide (once-weekly injection) or semaglutide (once weekly) – injectable GLP-1 receptor agonists (incretin mimetics)
These are injections that increase hormones called ‘incretins’, which help you make more insulin, reduce the amount of sugar produced by the liver, and slow the speed of digestion. They may also reduce appetite. They also have amazing effect on weight reduction. And some of these medications are recognised as weight reduction drug even with out diabetes. They are beneficial for patients with IHD.
These are generally well tolerated. But they have common gastrointestinal side effects, such as nausea and vomiting. Rarely they can cause pancreatitis, pancreatic and medullary thyroid cancer. You BMI should be more than 35 kgm-2 to be eligible for these injections. Semaglutide has an oral preparation. But is it less effective than the injectable form.
You may have a daily injection, twice daily or once weekly.
8. Linagliptin (alogliptin and sitagliptin) – DPP-4 inhibitors
DPP-4 inhibitors work by blocking the action of DPP-4, an enzyme that destroys the hormone incretin (which stimulates insulin production).
It is widely used in type 2 diabetes and tolerated.
9. Insulin
Insulin is kept as the last option for type 2 diabetes. But some patients may need it earlier on, e.g. if they are are prone to ketoacidosis (DKA). There are many different types of insulin. Most patients use a combination of a once daily ‘basal insulin’ which acts throughout the day; and take a ‘bolus insulin’ to cover meals. #
You should not be frightened of starting insulin as it is safe and may be the best mode of treatment for your diabetes.
10. Atorvastatin – HMG-CoA reductase inhibitor (statin)
Although not a DM drug, almost all patients with DM will need to be on a statin to reduce their cardiovascular risk.
4 step approach to management of type 2 diabetes
- Metformin. In general in type 2 diabetes, you will be started on standard release metformin and the dose slowly increased to a maximum tolerated dose. If you have gastrointestinal side effects, you may changed to a modified release preparation.
- Second/third agent. If your HbA1c is not under control your doctor will add on second oral medication. This will either be a DPP4 inhibitor (e.g. sitagliptin), sulfonylurea (e.g. gliclazide or glimepiride) or pioglitazone. If you have albumin (a protein) in your urine, or CKD, or chronic heart failure (CHF), it is more likely that you will be started on a SGLT2 inhibitor (dapagliflozin, empagliflozin or canagliflozin); as they are protective against further kidney damage and heart failure. A third drug is sometimes added.
- GLP-1 angonist. If triple therapy – i.e. metformin and two other oral drugs – is not effective or not tolerated, your doctor should consider switching one drug for a GLP-1 receptor agonist (liraglutide, semaglutide or dulaglutide). The decision to continue this injection is determined by the percentage improvement in sugar levels and weight reduction.
- Insulin. If all of the above fails to control blood glucose, you may need insulin therapy.
[“Yes, it is a complicated area, with new medicines and medications appearing all the time.” MyHSN Ed]
Summary
We have described what are the 10 best drugs to treat diabetes. We hope it is clearer now.
