The mainstay of treatment in type 2 diabetes is lifestyle change – weight loss, a structured exercise programme and a diet low in fat and with plenty of fruit and vegetables. Any diabetic should consult a dietician early in the disease to work out the correct diet for their lifestyle. It is of utmost importance that individuals attempt to stop smoking, and if it is not possible to stop, reduce the habit to an absolute minimum.
However, recent research has shown that in most people, even the correct diet along with exercise will eventually not be sufficient to control their blood glucose and that drugs have to be used.
The broad range of metabolic defects present often requires treatment with combinations of more than one drug. Increasing doses of medications and insulin injections may be required to control the blood sugar. The blood sugar levels should be reviewed by the patient’s doctor on a regular basis.
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The medications used for treating type 2 diabetes have the following aims:
1. To regulate blood sugar levels
2. To prevent or treat complications due to type 2 diabetes.
1. Medication to regulate blood sugar levels
Medications available to lower blood sugar can be divided into two groups, namely insulin and all other anti-diabetic medication.
1.1 Non-insulin medication options
Most of these medications are available in tablet format (known as oral hypoglycaemic agents (OHAs), which literally means glucose-lowering medication taken by mouth). However, one of the newer generation anti-diabetic medications is only available as an injection.
There is an increasing array of tablets that are effective in lowering glucose levels in type 2 diabetics. They differ in their modes of action, side-effects, cost and dosing schedule. The choice of the most suitable one needs to be made on an individual basis after a full medical assessment.
The main groups of oral blood glucose-lowering tablets are:
- Biguanides (e.g. metformin)
- 2nd generation sulphonylureas
- Thiazolidinediones (relatively new)
- Alpha-glucosidase inhibitors (a recently developed class)
- Meglitinides (also new)
- Incretin mimetics (GLP-1 agonists, also new)
- DPP-4-inhibitors (the latest anti-diabetic medication)
- Amylin agonists
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Insulin injections may be necessary in controlling the sugar levels and are usually started when non-insulin medications become ineffective. Insulin treatment should not be delayed once the sugar levels are not adequately controlled with tablets.
Although insulin injections are usually associated with type 1 diabetes, chances are that a person with type 2 diabetes will eventually need insulin therapy. Insulin injections are usually started when the pancreas does not produce any more insulin at all. Insulin is often combined with metformin (or some of the newer non-insulin diabetic medication) as this increases the patient’s sensitivity to insulin and often reduces the dose of insulin that is needed.
For years, doctors only prescribed insulin therapy for diabetics when all else has failed. However, things have changed. Now, some experts advocate earlier introduction of insulin in the treatment of type 2 diabetes because it actually protects the remaining insulin-producing cells in the pancreas.
There are different types of insulin; in fact insulin can be categorised according to its origin (human, animal or synthetic) and its function (rapid-acting, intermediate-acting or slow-acting etc). Your doctor will determine which one will best suit your needs.
2. Medications that help prevent or treat the complications of diabetes
It is imperative that the associated metabolic problems in type 2 diabetes are adequately treated as this has been shown to help prevent the serious cardiovascular and other complications for which the diabetic patient is at risk.
The most important conditions that require treatment are hypertension and the lipid abnormalities, both of which are commonly associated with type 2 diabetes.
Some of the commonly used medications which offer specific benefits in diabetes include:
ACE Inhibitors: (e.g. Ramipril/Tritace or Ramace, Perindopril/Coversyl, Lisinopril/Zestril, Captopril/Capoten). These are antihypertensive medications which may offer additional protection against kidney and cardiovascular complications.
ARB's: (e.g. losartan/Cozaar, irbesartan/Approvel). These are used to treat hypertension and have also recently been shown to be of benefit in slowing the progression of the kidney complications in type 2 diabetics.
"Statins": (e.g. atorvastatin/Lipitor, pravastatin/Prava, simvastatin/Zocor). While a low-fat and low-cholestrol diet is important in diabetics, it is often insufficient. The "statins" are a powerful group of cholesterol lowering agents that are useful in treating the abnormal lipid profile and helping to achieve the strict targets for cholesterol that need to be attained in order to lessen the risk of cardiovascular disease.
Aspirin: has been shown to be of benefit in preventing cardiovascular events such as heart attacks and strokes and should be used in type 2 diabetics who are at risk or who have a history of previous cardiovascular events.
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