A number of new medications for type 2 diabetes have become available in recent years, giving people with the disease a wider range of options for treatment. “Lifestyle management—nutrition, exercise, stopping smoking, and weight loss—remains the most important first step for type 2 diabetes management,” says Valentine J. Burroughs, MD, an endocrinologist at Highland Medical P.C., “But if those steps aren’t enough, we now have a variety of treatments in our toolbox.”

People with type 2 diabetes produce some—but not enough—insulin, the hormone that regulates the amount of sugar in the blood. In contrast, people with type 1 diabetes do not produce any insulin.

When a person is diagnosed with diabetes, the doctor will determine if they have type 1 or type 2. The doctor will use a blood test called A1C to diagnose both types of diabetes. The A1C test result reflects a person’s average blood sugar level for the past three months. Once you have been diagnosed, the test is also used to see how well you are controlling your blood sugar. “The goal is to get the A1C down to 7% or below to avoid complications from diabetes,” Dr. Burroughs said.

Treatment Steps for Type 2
The first step for managing type 2 diabetes is lifestyle management. If these steps don’t lower your blood sugar sufficiently, your doctor will start you on a daily pill called metformin. “If the blood sugar is being controlled with lifestyle management and metformin, we continue to monitor a patient’s blood A1C level every three to six months,” Dr. Burroughs said. “If their A1C level is rising, first we make sure they are adhering to their diet and exercise plan, and that they are taking their medication properly.”

If after these steps the doctor determines blood sugar levels are still too high, the next step is adding a second medication. “In the past, doctors would wait six or eight months, even a year, before changing a diabetes patient’s medication regimen,” Dr. Burroughs said. “Today, we give a three-month trial, and if it’s not working, we add another medication.” If two drugs aren’t controlling blood sugar, a third drug may be added.

There are a number of newer diabetes drugs that can be added to metformin, according to guidelines from the American Diabetes Association. These include:

Oral Agents

• SGLT2 inhibitors, which work by preventing the kidneys from reabsorbing sugar into the blood. Instead, the sugar is excreted in the urine.
• DPP-4 inhibitors, which help reduce blood sugar levels. These drugs increase the secretion of insulin only if a person’s blood sugar level is high. 

Injectable Medication

• If these drugs are not successful in controlling blood sugar, the doctor may add an injected drug called a GLP1 agonist. This medication slows digestion and helps lower blood sugar levels. As with DPP-4 inhibitors, these drugs only increase the secretion of insulin if blood sugar levels are high. GLP1 agonists can help with weight loss by reducing a person’s appetite and slowing down how fast food leaves the stomach.

If these combinations of treatments aren’t enough, the doctor may add insulin therapy. There are two types of insulin: fast-acting and slow-acting. Fast-acting insulin is taken before meals, to prevent blood sugar from shooting up when a person eats. It generally starts to work within 15 minutes, and lasts about two hours. Slow-acting insulin is usually taken before bedtime, so it will last overnight. Some diabetics who take insulin use a continuous insulin infusion pump, which delivers short-acting insulin 24 hours a day through a catheter placed under the skin.

“The downside of some of the new medications is they are more expensive, and we sometimes have challenges getting insurance companies to pay for them,” Dr. Burroughs noted. “It is one of the many reasons we encourage patients to do their very best to manage their lifestyle so they don’t need as much medicine to control their diabetes.”