Type 2 Diabetes: When Your Treatment Plan Changes

As common as Type 2 diabetes is, there is no one treatment plan that works for everyone with this condition. With Type 1 diabetes, the course of treatment is pretty specific: insulin. But in the case of Type 2 diabetes, treatment might consist solely of lifestyle changes (eating healthfully, losing weight, getting plenty of physical activity). Or, treatment might consist of taking a diabetes pill twice a day. Some people with Type 2 diabetes take three or four different types of medication. Some even take insulin.

The not-so-good news? Your treatment plan may need to change as your course of diabetes progresses. The good news is that there are a lot of treatment options for Type 2 diabetes.

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Why does Type 2 diabetes progress?

Type 2 diabetes is a condition that changes over time, and how and when it changes all boils down to how the body uses insulin. If you have prediabetes or have just developed Type 2 diabetes, the beta cells in your pancreas still work to make insulin, the hormone that helps to lower and keep the amount of glucose in your blood at a safe level.

Sometimes, those beta cells go into overdrive as the body struggles to deal with insulin resistance. Insulin resistance is when cells in your muscles, fat and liver don’t respond well to insulin and can’t easily take up glucose from your blood. But your beta cells can only do so much—without some kind of intervention, over time, they’ll start to peter out and eventually stop making enough insulin to keep up with the body’s demands.

What is the treatment for insulin resistance?

Insulin resistance is a hallmark of both prediabetes and Type 2 diabetes. If your prediabetes is caught early on, the primary course of treatment is:

• Weight loss (between 5 and 10 percent of your body weight)
• Physical activity (at least 150 minutes of moderate activity each week)
• Healthful eating that controls your carb intake

Research shows that this regimen can lower your risk of developing Type 2 diabetes by 58 percent. In some instances, your doctor may prescribe metformin, a common medication that helps to reduce insulin resistance.

If you have Type 2 diabetes, the regimen above is also recommended. However, it’s highly likely that your provider will prescribe metformin, or possibly another type of diabetes pill. Why? Unfortunately, many people who have Type 2 diabetes are not actually diagnosed until years later. By the time they’re diagnosed, they’re making about half of the insulin that they used to make before getting diabetes. Those beta cells just couldn’t keep up.

How does your doctor know when your treatment needs to change?

There are people who have Type 2 diabetes who successfully manage it without medication or with, say, metformin. If you are watching your carbs, keeping your weight within a healthy range and getting plenty of physical activity, you may be able to avoid or delay starting on a new medication or increasing the dose. But how do you know that your efforts are working?

Your doctor should be checking your A1C regularly (at least twice a year, if not four times a year). He or she will use your A1C as a benchmark to make (or not make) a treatment change. For example, the A1C goal for many people with diabetes is less than 7 percent. Ideally, if you start on a medication, your A1C should be checked three months later. If it’s not at goal, you may need A) an increase in your medication dose, B) a new medication or C) both.

You can also keep tabs on how your treatment plan is working by checking your blood sugars regularly with a meter.

How does your doctor know which type of medication to start you on?

There are nine classes of diabetes pills. There are non-insulin injectable medications calls GLP-1 agonists. And then there’s insulin. It’s great that there are so many medications to choose from. However, because there are so many, it can sometimes be confusing for your doctor to know which one(s) to choose. Fortunately, there are guidelines and algorithms to help your doctor make that decision. But make sure you’re part of the decision-making. Do your homework (check out my eight-part series for more information on different types of diabetes meds, including metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors, alpha-glucosidase inhibitors, bile acid sequestrants and dopamine receptor agonists, non-insulin injectable diabetes medications and insulin) and ask questions. Here are some things to consider to help you and your doctor choose wisely:

Effectiveness: How well is the medication expected to lower your blood sugar and your A1C?

Side effects: What kind of side effects might you experience? For example, sulfonylureas, meglitinides and insulin can cause hypoglycemia (low blood sugar). Thiazolidinediones and insulin may lead to some weight gain. SGLT2 inhibitors can raise the risk of having a urinary tract infection. GLP-1 agonists may initially cause nausea.

Cost: Some of the newer medications on the market (DPP-4 inhibitors, GLP-1 agonists, SGLT2 inhibitors) can be pricey, and your health plan may not cover them. Find out what your health plan will cover and don’t be afraid to tell your doctor if a medication is too expensive for you. Less expensive drugs include metformin, sulfonylureas and Regular and NPH insulin. You may even be able to get some of your diabetes medications for just $4 at certain pharmacies. If you need assistance with paying for medications, check out patient assistance programs such as NeedyMeds or Partnership for Prescription Assistance.

Other health conditions: Metformin, which is frequently prescribed, is not appropriate for someone with significant kidney disease or congestive heart failure. GLP-1 agonists may not be the best choice for you if you have gastroparesis.

Other benefits: Certain diabetes medications do more than lower your blood sugar and A1C. Some provide other benefits, too, such as a lower risk of heart disease (metformin, SGLT-2 inhibitors) or weight loss (GLP-1 agonists). Again, look into the various medications and ask your doctor about the pros and cons of any new medication you are thinking of starting.

Pill vs. injectable: Swallowing a pill seems a whole lot easier than injecting a medicine. Understandably, having to give yourself a shot can seem scary. And while no one likes needles, needles used today are super-thin and much shorter than in years past—this means that the “ouch” factor is greatly reduced. In fact, most people don’t mind giving an injection one bit. If you’re hesitant about injections, ask your doctor for a referral to a diabetes educator. He or she can show you the ropes of injections, and even guide you through giving your first injection.

Routine and quality of life: Some diabetes medications should be taken right before eating a meal and at the same time each day. Others can be taken with or without food and time of day isn’t so much of an issue. If you’re feeling like your medications are impacting your schedule or quality of life, talk with your doctor about other options, such as switching your type of medication or taking an extended-release version, for example.

Starting on insulin means you’re a failure, right?

Absolutely not! There’s a lot of emphasis placed on “diet and exercise” for managing diabetes. No doubt, they’re extremely important and will always be a foundation for helping you manage your diabetes. But the reality is that, because Type 2 diabetes changes over time, diet and exercise may not be enough. And sometimes diabetes pills aren’t enough, either. Your body needs insulin. If your body isn’t making enough, you need to replace what you’re missing. That’s not a sign of failure.

Can you ever get off your medications?

It depends. If you are new to diabetes and take metformin, for example, you may be able to come off it (or at least lower the dose) if you lose weight and amp up your activity. However, the longer you’ve had diabetes, the less your chances of coming off your meds, especially if you’re taking more than one type of medication.

Bariatric surgery (such as gastric bypass surgery) has been shown to help many people with Type 2 diabetes go into remission. So it’s possible to be able to stop taking diabetes medication in this situation. (It’s important to note that bariatric surgery is not a cure for diabetes.)

If your treatment plan needs to change…

Keep tabs on your diabetes as much as you can: that means checking your blood sugars with a meter or using continuous glucose monitoring, keeping your appointments with your doctor and keeping track of your diabetes “numbers” (A1C, blood pressure, cholesterol, kidney function tests).

Do your homework: Your doctor may or may not keep you posted on new or different medications, so it’s up to you to stay informed about your options.

Keep an open mind: Don’t lose sight of how much eating and activity can impact your diabetes, but realize that they may not be enough to help you keep your “numbers” in a healthy range.

Want to learn more about the role of medicines in treating diabetes? Read diabetes educator Amy Campbell’s eight-part series on diabetes drugs, covering metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors, alpha-glucosidase inhibitors, bile acid sequestrants and dopamine receptor agonists, non-insulin injectable diabetes medications and insulin.

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  • RAWLCM

    There was yet another study recently indicating pre-diabetics given insulin immediately are far less likely to develop type 2 over time compared to those who start with diet, then pills, then get insulin after all else fails. To date, however, it doesn’t look like that is informing anyone’s practice. Insulin is still viewed by most as the medication of last resort.