Diabetes affects nearly 11 percent of the U.S. population. For people living with diabetes, they may be prescribed medication to help them manage their condition.
Reshmi Srinath, MD, Associate Professor of Medicine (Endocrinology, Diabetes, and Bone Disease) at the Icahn School of Medicine at Mount Sinai and Director of the Mount Sinai Weight and Metabolism Management Program, discusses medications that are available for type 2 diabetes and what you need to know.
There are many different types of medications for type 2 diabetes, including pills and injections. What are the most common treatments, and what are the pros and cons?
There are numerous medications; however, our mainstay starting drug is metformin, a medication that works to relax the pancreas, which produces insulin and make the body more sensitive to insulin. It also reduces liver glucose production and lowers appetite. We start metformin for any patient who has prediabetes or type 2 diabetes that is uncontrolled. It also lowers inflammation and reduces cancer risk.
Newer diabetes medications work on the gut. These are daily or weekly injections that target a hormone that comes from your small intestine called glucagon-like peptide (GLP). These medications help the pancreas control blood sugar and produce insulin. They also have a significant benefit for weight loss as they slow the way food travels through your gut, which leads you to get full quicker and eat less, which helps control your glucose levels.
There is also another class of medications called SGLT2 inhibitors—pills that relax the kidneys and help them filter sugar. They also can help you improve your blood pressure and regulate your weight. Numerous studies have shown benefits from these medications in reducing the risk of heart disease and heart failure and reducing stroke risk. Lastly, there is insulin, our most potent medication that helps regulate blood sugar.
How well do these medications work?
Most medications on the market are quite effective. They help to lower your blood sugar and a marker called hemoglobin A1C, a diabetes risk marker where values over 6.5 percent correlate with type 2 diabetes. Values between 5.7 and 6.4 percent correlate with prediabetes, which is very important for our patients to know. We know that a majority of these medications do help to lower hemoglobin A1C, at least 1 to 2 percent.
What are some of the more significant side effects?
Injectables that work on GLP1 affect the gastrointestinal system, and the most common side effects include bloating, flatulence, and constipation. They also can activate gastric reflux, and potentially worsen constipation. The SGLT2 inhibitors work on the kidney. People on these describe feeling more thirsty, and that they are peeing more. Occasionally, patients may develop urinary tract or yeast infections.
Metformin is well tolerated. People do describe some gastrointestinal side effects in terms of some stomach upset bloating and nausea, but usually that goes away within the first week. The main risk with insulin is making sure patients aren’t developing low blood sugar due to too much insulin being administered.
Why is it important to take medications for type 2 diabetes?
It is very important you take medications. We know that diabetes is tightly linked to the risk of heart disease and stroke, which can be associated with greater mortality and morbidity. We know that diabetes, when uncontrolled, can lead to complications, including vision problems and potentially blindness. Diabetes can also lead to worsening kidney function and potentially kidney failure.
Diabetes itself can lead to symptoms of numbness, tingling in the hands and feet, which can eventually lead to a condition called neuropathy, where patients can actually lose sensation in their extremities, particularly the feet, which can lead to risk of injury, foot ulcers, and potential amputation. These are complications we want to avoid. I think the first step is really being vigilant and taking preventative measures, including taking your medications, being closely monitored by your physician, and monitoring your blood sugar.
Medications to treat type 2 diabetes have been in the news. What are they, and how do they work?
A lot of these medications have been in the news recently because they both help to manage type 2 diabetes and weight, which is a risk factor for type 2 diabetes. By helping patients lose weight, we can prevent them from developing type 2 diabetes. For example, you may have heard of drugs like Ozempic® and Mounjaro™, these are injectables that both work to help control diabetes but also have significant weight loss benefits.
We now have FDA approved versions of these, which are indicated for weight loss. Ozempic® has now what we consider a companion called Wegovy®, both known as semaglutide. These are both medications that work similarly. They’re the same drug, but Wegovy is approved for weight loss, and Ozempic® is approved for type 2 diabetes. Similarly, Mounjaro™, which is one of the newest drugs for type 2 diabetes, is being tested for obesity, and will likely get FDA approval for obesity.
In general, who are the most appropriate candidates for these drugs?
This is really a conversation to have with your primary care doctor or endocrinologist. As I mentioned earlier, obesity and weight gain are risk factors for type 2 diabetes. It’s important that you keep an eye on your blood test results and blood sugar.
We typically assess diabetes risk by looking at fasting blood sugar and at hemoglobin A1C, and sometimes patients even do a glucose tolerance test, which is another way of determining if patients have a risk for diabetes. For patients who definitely have diabetes risk, it is important to have a conversation about your weight and whether you might be candidate for some of these medications, which are FDA approved for obesity. Many medications approved for type 2 diabetes are being closely regulated by insurance companies, so it is now getting harder to get these structures purely off label.