When a person is diagnosed with type 2 diabetes, their A1C at that time determines how their condition should initially be managed. The target A1C for most people with diabetes is 7% or lower. How close you are to that target will help your healthcare team determine how best to manage your diabetes.
Regardless of A1C, however, healthy behaviour choices should always be discussed at diagnosis, as they are the cornerstones of diabetes management. These include eating a healthy diet, incorporating physical activity into your daily or weekly routine, quitting smoking and attaining an ideal weight. There are many medication options. The following three main criteria help guide the choices.
- The routine is acceptable by you (e.g. complexity, affordability, pills vs. injections, changes in weight, risks of low blood sugars)
- Whether you have pre-existing cardiovascular disease (some medications are protective beyond their ability to lower blood sugar)
- Ability of medication to attain various targets (e.g. A1C, BP, weight, little hypoglycemia)
At diagnosis – if A1C is between 7.1 and 8.5%
If the A1C at diagnosis is less than 1.5% above target (i.e. an A1C between 7.1% and 8.5% for most adults) and there are no symptoms of hyperglycemia, healthy behaviour choices should be implemented with or without the addition of medication and the A1C can be reassessed after three months. If the target has not been achieved at that time, then lifestyle changes should be combined with medication therapy.
If your A1C is not at target after three to six months, your healthcare team will likely prescribe a second medication. The treatment regimen should be individualized, and a conversation between you and your healthcare team will help determine which medications are best for you.
At diagnosis – if A1C is over 8.5%
If there is significant elevation of the blood glucose at diagnosis (i.e. over 8.5% for most adults), medication is usually started right away, along with healthy lifestyle interventions. Usually, if two medications are started together, there is a faster reduction of A1C levels and a higher chance of getting to A1C target after six months of treatment, compared with starting one medication alone. Therefore, starting with more than one medication may be considered for people with very high initial blood sugar levels to get the necessary A1C decrease.
If there is “metabolic decompensation” at diagnosis (i.e. very high blood sugar levels, with symptoms of frequent urination and thirst or unintentional weight loss), insulin should be started immediately, regardless of a person’s A1C.
Medications for diabetes management
The number of diabetes medications coming to market is growing annually. Healthcare professionals now have the ability to choose medications that not only lower blood glucose levels but also have other beneficial effects for people with type 2 diabetes. These effects include: reducing the risk of diabetes complications (such as heart disease); reducing the risk of hypoglycemia and weight gain. There are other considerations such as: affordability of medications; medical history and other concurrent diseases and patients’ values and preferences. The question becomes, what should be added and why?
If you have:
Cardiovascular (heart) disease
In adults with type 2 diabetes who have had a cardiovascular event, such as a heart attack, stroke, heart failure, amputation or have peripheral artery disease, there are several medications that can be of benefit as an add-on therapy depending on the patient’s medical history. In addition, some medications are recommended to reduce the progression of kidney disease in people with elevated A1C and cardiovascular disease. If this applies to you, discuss what options are available with your doctor.
Risk of hypoglycemia
Some medications can cause hypoglycemia (low blood sugar). For elderly people and those with kidney or liver dysfunction, there is an increased concern regarding the risk of hypoglycemia. Hypoglycemia can be dangerous in these populations, therefore, the class of drugs called insulin secretagogues (which include meglitinides and sulfonylureas) should be avoided. The better options would be DPP4 inhibitors, GLP-1 receptor agonist, or SGLT2 inhibitors, which have a very low risk of causing hypoglycemia.
Issues with weight
Some medications used to manage diabetes can cause weight gain, while some can cause weight loss. There are also others that are “weight neutral,” which means that they don’t cause weight gain or weight loss. If change in weight is a concern to you, discuss which are the best options for your situation.
Cost or coverage concerns
When out-of-pocket expenses need to be taken into consideration, don’t be afraid to address this with your diabetes care team. Your primary care provider and pharmacy team can help you determine specific coverage options that are most suitable for you. Be sure to mention if cost is a barrier to your care.
It is important to review contraindications to specific medications with your healthcare team. For instance, if there is reduced kidney function, multiple medications may be ruled out. If there is a history of bladder cancer or heart failure certain medications cannot be used, while other ones may be preferable. It is important, therefore, that your healthcare team know your complete medical history before choosing a medication.
Patient preferences can play a large role when choosing add-on therapy. Some medications are injected (i.e. GLP-1 agonists and insulin), instead of taken by mouth. Some require multiple doses per day (i.e. acarbose and meglitinides), as opposed to once-daily DPP-4 inhibitors or even once-weekly injectables. As well, there may be side effects that prevent people from taking certain medications. It is important to remember that every drug has a risk of side effects, although specific side effects may only happen to a handful of people. It’s always best to talk with your healthcare team about the risks of side effects with diabetes medications.
How often should medications be re-assessed?
An individual’s A1C should be monitored every three to six months, at which time the current medication regimen should be reassessed in order to attain target A1C. If not at target, dose adjustments can be made or a medication from another class can be added to an existing regimen. Even after reaching target, it is important to be reassessed regularly, as even well-controlled diabetes progresses over time – meaning the treatment plan may have to be adjusted more than once.
What is the role of insulin in type 2 diabetes?
As well as being used at diagnosis for people with very high blood glucose levels, insulin may be used at any time during type 2 diabetes management. If a person is not achieving blood glucose targets on an existing medication regimen, the addition of a once-daily basal (long-acting) insulin regimen should be considered.
It’s best to discuss the pros and cons of different treatment plans with your healthcare team. Together, you can decide which medication is best for you after considering the aspects that are most important to you and your overall health.