Treatment and medication

Long term conditions: Diabetes Blood Test Equipment

People with type 2 diabetes often need medication, in conjunction with making lifestyle changes, to control their diabetes, blood pressure and blood fats. This section helps to explain more about the common treatments for people with diabetes. Remember that the information in this section is general information and it is important that you discuss any concerns or problems you may have with your medication and treatment with your healthcare team.

The purpose of making lifestyle changes and taking medication is to control the level of glucose in your blood.

Blood glucose targets (self-monitoring of blood glucose levels)

Self-monitoring of blood glucose may be an important part of your diabetes management. As part of your daily or weekly routine, blood glucose monitoring results, will help to inform you of any necessary lifestyle and medication changes, as well as help to monitor for symptoms of hypo- or hyperglycaemia, or signs of long term complications

For many people, the aim is to keep your blood glucose levels in or close to the normal range - that of a person who does not have diabetes. 

Normal blood glucose ranges are:

  • 3.5-5.5mmol/l* before meals
  • less than 8mmol/l, two hours after meals.

Your diabetes healthcare team will discuss your individual target ranges with you, but they are likely to be as follows (based on NICE guidelines, 2008) 

  • Before meals: 4-7mmol/l
  • Two hours after meals: less than 8.5mmol/l

*Mmol/l is millimoles per litre: a measurement of the concentration of a substance in a given amount of liquid.

Lifestyle changes

For many people with type 2 diabetes, treatment at least to begin with, will be making changes to your lifestyle, including taking regular exercise, eating a healthy diet and losing weight if you are overweight or obese. Doing this may be enough to keep your blood glucose at a safe and healthy level, without the need for other treatment.

Type 2 diabetes usually gets worse over time. Even if they work at first, diet and exercise may not be enough to control your blood glucose levels forever.

Medication

If regular exercise and a healthy diet are not effective in controlling your blood glucose levels, you may need medicines to treat type 2 diabetes. Diabetes medication will not cure your diabetes and most people will have to take medication for the rest of their lives. It will, however, help you to feel better by relieving the symptoms of diabetes and reducing your risk of complications. 

If you take medication, it is important to know how it works, and to be aware of the potential problems/side effects you may have. Remember that you can always discuss any questions you may have about your treatment with your GP or diabetes specialist nurse. 

Diabetes medication should be taken in conjunction with diet and physical activity. 

Increasing or changing diabetes medication is not a sign that your diabetes is becoming more severe, but that your healthcare team are working with you to improve your diabetes management. 

There are several different types of medicines, usually taken as tablets that are used to treat type 2 diabetes. You may need to take a combination of two or more medicines to control your blood glucose level. 

Metformin
Metformin is often the first medicine that is recommended to treat type 2 diabetes. It works by reducing the amount of glucose that your liver releases into your bloodstream. It also makes your body's cells more responsive to insulin. 

If you are overweight, it is likely that you will be prescribed metformin. Unlike some other medicines that are used to treat type 2 diabetes, metformin should not cause additional weight gain. However, it can sometimes cause mild side effects, such as nausea and diarrhoea and you may not be able to take it if you have kidney damage.

Sulphonylureas
Sulphonylureas increase the amount of insulin that is produced by your pancreas. Examples of sulphonylureas include:

  • glibenclamide
  • gliclazide
  • glimerpirizide
  • glipizide
  • gliquidone

You may be prescribed a sulphonylureas if you cannot take metformin or if you are not overweight. You may be prescribed a sulphonylurea and metformin if metformin does not control blood glucose on its own.

Sulphonylureas can increase the risk of hypoglycaemia (low blood glucose) because they increase the amount of insulin in your body. Sulphonylureas may sometimes cause side effects including weight gain, nausea and diarrhoea.

Glitazones (Thiazolidinediones, TZDs)
Thiazolidinedione medicines (pioglitazone) make your body's cells more sensitive to insulin so that more glucose is taken from your blood. They are not often used alone, but are usually used in addition to metformin or sulphonylureas, or both. They may cause weight gain and ankle swelling. Do not take pioglitazone if you have heart failure or if you have a high risk of bone fracture.

Another thiazolidinedione, rosiglitazone, has been withdrawn from use because of the increased risk of cardiovascular disorders, including heart attack and heart failure. If you are currently taking rosiglitazone, you should continue to take the medicine as prescribed. You should also make an appointment to see your healthcare team to discuss alternative medication. 

Gliptins (DPP-4 inhibitors)
Gliptins work by preventing the breakdown of a naturally occurring hormone called GLP-1. GLP-1 helps the body produce insulin in response to high blood glucose levels, but is rapidly broken down. By preventing this breakdown, the gliptins (sitagliptin and vildagliptin) act to prevent high blood glucose levels, but do not result in episodes of hypoglycaemia. You may be prescribed a gliptin if you are unable to take sulphonylureas or glitazones. They are not associated with weight gain.

GLP-1 agonists
Exenatide is a GLP-1 agonist, an injectable treatment that acts in a similar way to the natural hormone GLP-1 (see section on gliptins, above). It is injected twice a day and boosts insulin production when there are high blood glucose levels, reducing blood glucose without the risk of hypoglycaemic episodes ('hypos'). It also leads to modest weight loss in many people who take it. It is mainly used in people on metformin plus sulphonylurea who are obese (with a BMI of 35 or above).

Another GLP-1 agonist called liraglutide has recently been launched in the UK. It is a once daily injection (exenatide is given twice a day). Like exenatide, it is mainly used in people on metformin plus sulphonylurea who are obese, and in clinical trials it has been shown to cause modest weight loss.

Acarbose
Acarbose helps prevent your blood glucose level from increasing too much after you eat a meal. It slows down the rate at which your digestive system breaks carbohydrates down into glucose.

Acarbose is not often used to treat type 2 diabetes because it usually causes side effects, such as bloating and diarrhoea. However, you may be prescribed acarbose if you cannot take other types of medicine for type 2 diabetes.

Nateglinide and Repaglinide
Nateglinide and repaglinide stimulate the release of insulin by your pancreas. They are not commonly used but may be an option if you have meals at irregular times. This is because their effects do not last very long, but they are effective when taken just before you eat.

Nateglinide and repaglinide can cause side effects, such as weight gain and hypoglycaemia (low blood glucose).

Treatment with insulin

All people with type 1 diabetes will require insulin and eventually, some people with type 2 diabetes will find that despite having their diabetes medication adjusted, their blood glucose levels remain too high and insulin treatment is recommended by their GP. This may be taken alongside other medication. Your healthcare team will be able to discuss the right medications for you.

Insulin can be given via an injection, using a syringe, pen device or via an insulin pump. As insulin is a protein, it cannot be ingested as it would be digested before it had a chance to work.

Insulin is injected just under the skin (subcutaneously), either in the stomach, buttocks, thighs or upper arms. The insulin is then absorbed into small blood vessels.

There are six main types of insulin available in various combinations and they all work in different ways. Your diabetes healthcare team will discuss the different options available and answer any specific questions you may have. 

Side effects

All medicines can have side effects and these are listed alongside each medicine described above. You may or may not experience any of these. However, if you do, speak to your doctor as there may be another medication which could be used instead.

If you think a medicine has caused a side effect, or even if you are unsure, you can report the problem to the Medicines and Healthcare Products Regulatory Agency (MHRA) on a 'yellow card'.

Yellow card forms are available from pharmacies and other outlets across the NHS. 

If you are taking diabetes medication it is important to:

  • Know what it is
  • Know why you are taking it
  • Know how it works
  • Know when to take it
  • Be aware of the possible side effects you may have
  • Remember that medication is not a substitute for following a healthy diet and taking regular physical activity; you will still need to carry on with this.