There is no drug that will do for you what eating well, moving your body, self-love and mindfulness can. - Bridget Jane.

We’re living in a modern world where cars drive themselves, veggies grow in a lab, and the number of medications developed surpass the total number of diseases they are meant to treat.

The pharmaceutical sector offers solutions for just about anything; from multiple over-the-counter remedies for a common cold to low demand orphan drugs created to treat conditions so rare that it affects just 1 in 2000 people. So it comes as no surprise that a rampant chronic condition like Type - 2 Diabetes has a constantly growing number of medications under different categories to help manage high blood sugar levels.

To understand how medications can help manage your Prediabetes or T2 Diabetes, you will need to understand the Pathophysiology of Diabetes - or in plain words - what causes Type 2 Diabetes?

Type 2 Diabetes - The Origin Story

Where?

More often than not, developing Pre-diabetes or Type 2 Diabetes is typically due to lifestyle - related causes like Insulin resistance. Insulin resistance results from a combination of increased belly fat, physical inactivity, a diet high in processed carbs, reduced sleep, increasing age, and genetic predisposition, but is most commonly seen in individuals who are overweight or have a higher waist to height ratio.

Why?

Consuming a diet high in sugars and calories results in high levels of fat in your blood thereby leading to increased body fat (especially belly fat). This dangerous belly fat that accumulates around your organs (also called visceral fat) releases many free fatty acids and inflammatory hormones into your blood, causing the cells of your muscles and liver to stop responding properly and driving insulin resistance.

How?

In Insulin Resistance, your body turns resistant and is unable to use the produced insulin effectively enough to supply glucose energy to your own cells. This compels your pancreas to start producing more insulin to compensate. Over a period of time, the strain of producing all that extra insulin causes your pancreatic beta cells to wear out and eventually fail. Since your pancreatic beta cells are now unable to produce insulin effective enough to control blood sugar levels, your blood glucose levels start to rise.

To learn more about Insulin Resistance, check out our article on Insulin Resistance and Diabetes Reversal.

What?

A combination of your cell’s resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion and glucose production by your liver leads to an array of dysfunctions and characterized by - Hyperglycemia (high blood glucose levels in blood) and decline of B-cell function.

Medication Management of Type 2 Diabetes

Being diagnosed with Diabetes is an unsettling and difficult experience for anyone. This gets compounded further by a lot of misinformation on diabetes medicines that you either read, see or hear from known or unknown sources; both online and off. This barrage of information and opinions on the different classes, types, uses and comparisons of Antidiabetic medications is overwhelming and often brings up more questions than it answers, phew! But, Don't Fret! Regardless of whether you or a family member is recently diagnosed or have been living with diabetes for many years, we have your back!

We have compiled some of the most frequently asked questions about Diabetes management, medications and managing glycemic levels - all of which are science-backed and most importantly made simple and easy to understand by our in-house sugar.fit diabetes experts. So without further delay, let's dive right in.

Why is Hyperglycemia (High Blood Glucose Levels) dangerous?

Type 2 Diabetes Mellitus (T2DM) is not a condition that develops overnight. It is a progressive, gradual, and stretched over a period of time affected by several risk factors, multiple lifestyle related problems and genetic susceptibility. Although the word ‘progression’ is usually seen as having positive connotations, in Type 2 DM it is the other way around.

Progression describes a development that happens step-by-step and in stages. The threshold towards which this process inches is what makes it positive or negative. In T2DM, that threshold goal is to achieve Euglycemia - which is a normal level of Blood Glucose.

Having high levels of blood sugar over time and if left untreated, can progress to Prediabetes, Type 2 diabetes and long-term complications. It causes damage to your nerves, blood vessels, tissues and vital organs like the heart, kidneys, eyes and non-healing wounds making you feel like you're fighting a losing battle against your own body.

Progression of Hyperglycemia - If Left Untreated

Insulin Resistance    --->    Pre-diabetes    --->   T2D   --->   Complications

                                                                                                          -  Neuropathy & Amputation

                                                                                                          -  Retinopathy

                                                                                                          -  Heart disease & Stroke

                                                                                                          -  Kidney Disease

                                                                                                          -  Dermopathy

                                                                                                          -  Sleep Apnea

When do we need Medications for Type 2 DM?

Since the main cause of Type-2 diabetes is insulin resistance, the first line of management is often meal planning, weight loss, and exercising. Medicines are just one facet in the multi-modal management of diabetes. While it is true that drugs do help in lowering blood glucose, it is very much possible to achieve the same naturally with a healthy diet and moderate physical activity, but over a period of time. Now you may wonder, if it is that simple, why do we even need medications?  

While lifestyle changes such as dietary modification and increased physical activity can be very effective in improving glycemic control, sometimes these measures are not enough to bring blood glucose levels down near the normal range. This is where medications come in. Blood glucose lowering medicines are prescribed to combat and regulate the high levels of sugar in your blood and bring it down to a normal range.

What is the Role of Medications in the management of Type 2 Diabetes?

Medications to normalize blood sugar levels are not the be all and end all of Diabetes management.

Although anti-diabetic drugs will undoubtedly improve your blood glucose levels, that is not sufficient. Diabetes management should also seek to treat the whole individual, and not just their blood glucose levels. This means the management regime chosen should also target insulin resistance, islet cell dysfunction and help in reducing your long-term risk of other comorbidities and complications.

Here are the Top 4 Ways that medications help in Type 2 diabetes management.

  1. Maintain or improve the individual’s quality of life
  2. Attain optimal glycemic control for the individual
  3. Prevent or delay the onset and progression of complications like myocardial infarction, stroke, amputation, dialysis, and premature mortality.
  4. Minimize the potential adverse events related to treatment like hypoglycemia and weight gain (insulin therapy)

What are Hypoglycemic Drugs and how do they work to treat Type - 2 Diabetes?

Antidiabetic medications; also called Hypoglycemic agents, help in reducing or lowering the high blood sugar levels to achieve glycemic control. Most medications for type 2 diabetes are Oral (taken by mouth), but a few come as injections as well. These oral diabetes medications may be taken on their own, in combination with each other or with insulin in order to achieve the best blood glucose control.

Medications for Type 2 Diabetes work in different ways to reduce blood glucose levels.

  • Increase Insulin output by the Pancreas
  • Increase the Sensitivity (response) of cells to Insulin
  • Decrease the amount of Glucose released from the Liver
  • Slow emptying of the stomach, thereby delaying nutrient Digestion.
  • Decrease Absorption of Carbohydrates from the Digestive tract

Most diabetes medications can effectively lower blood sugar and many of them provide more than one benefit, like reducing blood sugar and controlling cholesterol.  Since not every individual with type 2 diabetes will benefit from every drug, and not every drug is suitable for each patient, a variety of combinations can be advised to control diabetes. The medications for Type 2 Diabetes fall into specific classes based upon the way they work to achieve control of blood sugar.

What are the different categories of Oral Hypoglycemic Agents (OHA) and how do they differ from one another?

There are many types of OHA drugs that work in different ways, to achieve the same goal - lowering blood sugar levels. Outlined below are the various OHA Classes with actions & examples.

Table 1.0  : Diabetes Medication - 10 Classes of OHA’s

Class How it Works Examples
Biguanides
  • Reduces glucose production in the liver.

  • Improves the working of insulin.

  • Slows the conversion of carbs to sugar.
  • - Metformin
    Sulfonylureas
  • Stimulates pancreas to make more insulin.
  • - Glipizide
    - Glimepiride
    - Glyburide
    Thiazolidinediones
  • Improves the working of insulin

  • Allows more glucose to enter muscles, fat, & liver.
  • - Pioglitozone
    - Rosiglitazone
    Alpha-Glucosidase Inhibitors
  • Delays the breakdown of carbohydrates.
  • - Acarbose
    - Miglitol
    Meglitinides
  • Stimulates pancreas to make more insulin.
  • - Repaglinide
    - Nateglinide
    DPP-4 Inhibitors
  • Helps pancreas release more insulin after meals.

  • Reduces the amount of glucose released by the liver.
  • - Sitagliptin
    - Saxagliptin
    - Linagliptin
    - Alogliptin
    SGLT2 Inhibitors
  • Helps the kidneys remove extra sugar from the body.
  • - Canagliflozin
    - Dapagliflozin
    - Empagliflozin
    Bile Acid Sequestrant

  • Lowers cholesterol and blood sugar levels.

  • - Colesevelam
    Dopamine Agonist
  • Reduces the amount of glucose released by the liver.

  • - Bromocriptine
    GLP-1 Receptor Agonist
  • Increases B-cell Growth

  • Increases effectiveness of Insulin.

  • Decreases Appetite

  • Decreases Glucagon used by the body,

  • Slows rate of stomach emptying.
  • - Albiglutide
    - Dulaglutide

    Is Insulin the most effective treatment for all types of Diabetes?

    In Diabetes, your body is unable to utilize the energy from the food you eat, because of 2 main reasons

           1. Your Body’s incapability to make insulin ---> Type-1 DM OR Insulin-dependent Diabetes Mellitus (IDDM).

               People with Type 1 Diabetes must take insulin as part of their treatment, since their bodies can't make insulin anymore. So            Insulin therapy is very effective in Type - 1 DM.

           2. Your Body’s reduced efficiency in using Insulin ---> Type-2 DM OR Non-Insulin dependent Diabetes Mellitus (NIDDM)

    However, in Type 2 Diabetes, first-line treatment would be oral drug therapies using Metformin, Sulphonylurea derivatives or α-glucosidase inhibitors which can be used alone or in a combination with other OHA’s. Some individuals with Type 2 Diabetes may require insulin therapy as well in combination with other OHA’s to achieve adequate control of blood glucose levels.

    The Type of Antidiabetic medication required depends on the Type of Diabetes. Hence, Insulin therapy; although can be used, is not the go-to or first choice for medication management in Type 2 DM. Insulin therapy may be prescribed for Type 2 if you have symptoms of very high blood sugar, along with weight loss.

    To learn more about Insulin - how it works, the different types, benefits, limitations and its scope in the treatment of Type 2 Diabetes, check out our article on 101 Guide - Insulin.

    Table 1.1 below elaborates on why different types of diabetes have different goals of treatment based on the cause for the disordered metabolism.

    To learn more about your Metabolism, check out our article on 101 Guide - Metabolism

    Table 1.1  : Medication Management for Type -1 and Type -2 Diabetes.

    Type Pathophysiology or Cause Treatment Goal Type of Medication to be Used
    Type - 1 DM Body is incapable of making insulin. To replace the insulin that your body can’t make. i) Insulin
    - Short acting
    - Rapid-acting
    - Intermediate acting
    Type - 2 DM Body is capable of making insulin, but is either unable to use it well OR can’t make enough insulin to keep your blood sugar levels normal To help your body use the insulin better or get rid of extra sugar in your blood. i) Hypoglycemic Medicines
    - Oral
    - Injections
    ii) Insulin

    Are some Medications more effective than others? How will I know which medication is best for me?

    Despite considerable progress in treatment over the last 2 decades, diabetes is still a complex condition requiring medical correction. So why is it that we still see only a few individuals actually reach their target blood sugar goal?

    Currently, the number of anti-diabetic medications available is overwhelming, but each individual has their own goals, needs, and preferences while choosing the right drug. Your doctor is the best person to make this decision since it would involve observation and intermittent adjustment of the type or dosage of medicine to determine what works best for you.

    Effective management means using multiple risk-reduction strategies to achieve the target goal for blood sugar control, eliminate symptoms, and prevent or at least slow down the development of complications.

    Risks Risk Reduction through Medications
    i) Microvascular Complications
    - Eye
    - Kidney disease
    --> Control of Glycemia
    --> Control of Blood Pressure
    ii) Macrovascular Complications
    - Coronary
    - Cerebrovascular
    - Peripheral vascular
    --> Control of Lipids
    --> Control of Blood Pressure
    --> Smoking Cessation
    --> Aspirin therapy
    iii) Metabolic & Neurologic Complications --> Control of Glycemia

    What are the factors my doctor considers when choosing the right medication for me?

    To decide which medications will benefit you the most, your doctor will evaluate the following-

    1. Latest HbA1C Values
    2. Presence of heart disease, including past history of heart attacks, strokes, or other cardiac conditions.
    3. Presence of chronic kidney disease
    4. Risk of low blood sugar with any particular medications
    5. Proclivity to any potential side effects of the medicine
    6. Current weight and the potential for the medicine to affect your body weight

    Bottom Line

    While it may seem like medicines can do everything, the truth is they can't, and most importantly, they shouldn't.

    There is more to Life than Diabetes; and there is more to Diabetes than Drugs. The treatment of diabetes is a multifaceted approach involving not only medications but diet and lifestyle management; all of which are equal contributors to achieving Diabetes Reversal.

    Medications can help manage diabetes but cannot reverse it on its own as it does not address the root cause. Becoming dependent on medicines and/or believing that it is the only reliable way to manage diabetes is going to lead you down a treacherous path and one that's very tough to get back from. Think about it - what makes more sense? Correcting the problem that’s causing it?...or masking the symptoms with drugs, such that you're dependent on those pills for the rest of your life?

    Sugar.fit can help you take back control, with just simple habits changes along with holistic and personalized interventions ,to ensure you are well on your path back from Diabetes. So don't wait, and make this the year you reverse your diabetes .