Type 2 Diabetes Treatment

Type 2 diabetes is a condition that affects the way your body uses insulin, a hormone that helps regulate your blood sugar. It is often treated with Glucophage (metformin), a first-line diabetes drug that reduces the amount of sugar your body produces.

There's no one-size-fits-all treatment for type 2 diabetes, however. The key to managing this increasingly common condition is piecing together a treatment plan that fits the individual.

Type 2 diabetes treatment may include:

• Lifestyle changes
• Medication
• Surgery
  

This article looks at some of the approved ways to manage and treat type 2 diabetes.

Lifestyle Changes

Type 2 diabetes can often be treated by changing or beginning certain lifestyle practices. This is nearly always the first step in treating type 2 diabetes.

Weight loss is one of the primary goals of these lifestyle changes. A loss of just 5% to 10% of total body weight can have a dramatic effect on blood sugar levels in people with type 2 diabetes.

Some of the lifestyle changes to manage type 2 diabetes include:

• Diet
• Exercise
• Quitting smoking

Diet

It's especially important to reduce your carbohydrate intake. This can lead to weight loss, improved blood sugar control, and lower levels of triglycerides. Triglycerides are fats associated with an increased risk of heart disease.

There's no such thing as an official "diabetes diet." There are a variety of approaches to eating and nutrition that have been found to be helpful, though, including:

• The Plate Method: This is an easy way to help manage your blood sugar. It emphasizes non-starchy vegetables, whole grains, lean protein, and fiber. Fiber in particular can help to slow increases in blood sugar levels. Specific percentages of the plate are dedicated to certain foods.
• Carb consistency: Carbohydrates impact blood sugar more than protein and fat. Taking in the same amount of carbs at each meal will help keep glucose levels steady. For example, this might mean consistently eating 45 grams of carbs for breakfast and lunch, 15 grams of carbs for a between-meal snack, and 60 grams of carbs for dinner each day.
• Limiting foods that dramatically increase blood sugar levels: These include fruit juice, refined and processed carbohydrates like white bread and pasta, and sugary sweets such as cookies, cake, and candy. It's typically fine to eat two or three servings of fresh whole fruit per day.

Besides these basic guidelines, there's evidence that dramatically reducing carbohydrates can have a profound and positive impact on type 2 diabetes.

In one study, people with obesity and type 2 diabetes who followed a very carb-restricted diet for six months had lower hemoglobin A1C results. This test is a measure of blood sugar over a period of two to three months. Participants on the carb-restricted diet also lost more weight than those who followed a reduced-calorie diet. Both groups exercised regularly and had the support of group meetings.

This is just one study, however. Always consult your healthcare provider and/or a dietitian who specializes in diabetes before making major dietary changes.

Exercise

Regular exercise is critical for managing type 2 diabetes. Physical activity burns calories and may contribute to weight loss. Exercise can also have a direct impact on blood sugar control because insulin resistance is closely linked to increased fat and decreased muscle mass. When you have insulin resistance, your body doesn't use insulin the way it's supposed to.

Insulin helps your cells use blood glucose for energy. Muscle cells use insulin far more efficiently than fat. By building muscle and burning fat, you can help better control your blood glucose levels.

The American Diabetes Association (ADA) recommends the following exercise guidelines for adults with type 2 diabetes:

• 150 minutes or more of moderate-to-vigorous aerobic activity weekly: Spread this out over at least three days, with no more than two days in a row without activity.
• Two to three sessions of resistance exercise per week on nonconsecutive days: This includes things like weight training or bodyweight exercises.
• For older adults, two to three sessions per week of flexibility and balance training: This includes activities like yoga and tai chi.

The ADA also recommends that people with type 2 diabetes not sit for prolonged periods of time. Aim to get up and move about every 30 minutes or so.

Quitting Smoking

People who smoke are 30% to 40% more likely to develop type 2 diabetes than nonsmokers. Even using smokeless tobacco can increase diabetes risk. What's more, smokers with diabetes are more likely to develop serious complications.

People with diabetes who stop smoking see rapid improvements in their diabetes symptoms and overall health.

There are many approaches to smoking cessation. Discuss the options with a healthcare provider or certified diabetes educator (CDE). This will help you find the strategy that is most likely to work for you.

Prescription Medications

Type 2 diabetes treatment sometimes includes medication. This is usually the next step when dietary changes, exercise, and weight loss aren't enough to control blood sugar levels.

Some diabetes medications are taken orally, and others are injected.

Medication is not meant to be used as a substitute for healthy lifestyle changes. Because some diabetes medications can cause a drop in blood sugar before or after exercise, however, it is important to know how your body responds to exercise and how your medications may affect you.

Here are some of the drugs that have been approved by the Food and Drug Administration (FDA) for treating type 2 diabetes.

Oral Diabetes Medications

Sulfonylureas

Sulfonylureas are the oldest class of oral diabetes medications. They work by stimulating the pancreas to release more insulin into the bloodstream. They include:

• Glucotrol (glipizide)
• DiaBeta, Glynase (glyburide)
• Amaryl (glimepiride); also in combination with Avandaryl (rosiglitazone) and Duetact (pioglitazone)

Biguanides

Biguanides lower the amount of glucose being produced by the liver. They also make the body more sensitive to insulin. They include:

• Glucophage (metformin)
• Glucophage XR (extended-release metformin)

Thiazolidinediones

Thiazolidinediones sensitize muscle and fat cells to accept insulin more readily. These drugs pose certain health risks that will need to be considered before the drugs are prescribed.

• Avandia (rosiglitazone); also combined with metformin as Avandamet and with glimepiride as Avandaryl
• Actos (pioglitazone); also in combination with alogliptin as Oseni; with metformin as Actoplus Met; and with glimepiride as Duetact

Alpha-Glucosidase Inhibitors

Alpha-glucosidase inhibitors delay the conversion of carbohydrates to glucose during digestion. This helps to regulate blood glucose levels and prevent sugars from peaking too high.

• Precose, Prandase (acarbose)
• Glyset (miglitol)

Meglitinides

Meglitinides help stimulate insulin production when glucose is present in the blood. They are not as effective if blood sugar levels are low.

• Prandin (repaglinide); also in combination with metformin as Prandimet
• Starlix (nateglinide)

DPP-4 Inhibitors

Dipeptidyl peptidase-4 (DPP-4) is an enzyme that destroys hormones called incretins. These hormones help the body produce more insulin when needed. DPP-4 inhibitors work by blocking this enzyme.

• Januvia (sitagliptin); also in combination with metformin as Janumet and with ertugliflozin as Steglujan
• Onglyza (saxagliptin); also in combination with metformin as Kombiglyze XR; with dapagliflozin as Qtern; and with metformin and dapagliflozin as Qternmet
• Tradjenta (linagliptin); also in combination with metformin as Jentadueto and with empagliflozin as Glyxambi
• Nesina (alogliptin); also in combination with metformin as Kazano and with pioglitazone as Oseni

It's important to note that in August 2015, the FDA added a warning and precaution about a potential side effect of DPP-4 inhibitors: severe and potentially disabling joint pain. If you are taking a medication that contains a DPP-4 inhibitor and develop joint pain, let your healthcare provider know right away. You may need to switch to a different medication.

SSGT-2 Inhibitors

Selective sodium-glucose transporter-2 (SSGT-2) inhibitors lower blood sugar by causing the kidneys to remove glucose from the body through urine.

• Farxiga (dapagliflozin); also in combination with saxagliptin as Qtern; with saxagliptin and metformin as Qternmet XR; and with metformin as Xigduo XR
• Jardiance (empagliflozin); also in combination with empagliflozin and linagliptin as Glyxami and with empagliflozin and metformin as Synjardy
• Steglatro (ertugliflozin); also in combination with ertugliflozin and metformin as Segluromet and ertugliflozin and sitagliptin as Steglujan
• Invokana (canagliflozin); also in combination with metformin as Invokamet

Taking canagliflozin can increase the risk of amputation of a toe, foot, or leg due to infection or other complications. Call your healthcare provider right away if you have any pain; tenderness; sores; ulcers; a swollen, warm, reddened area in your leg or foot; fever or chills; or other signs and symptoms of infection.

Glucagon-like peptide (GLP-1) receptor protein

Rybelsus (semaglutide) oral tablet was approved as the first and only oral GLP-1 to improve control of blood sugar in adults with type 2 diabetes

Kerendia (finerenone) 

This drug is prescribed to people who have type 2 diabetes and kidney disease. It helps reduce the risk of kidney failure, heart attack, and heart failure.

Combination therapy

Trijardy XR (empagliflozin/linagliptin/metformin hydrochloride extended-release) was approved in January 2020 as the only triple combination oral therapy for type 2 diabetes. Trijardy combines Jardiance, Tradjenta, and metformin hydrochloride in one extended-release pill taken once daily.

Injectable Diabetes Medications

Incretin Mimetics

Also known as GLP-1 receptor agonists, incretin mimetics stimulate the production of insulin. They also slow the rate of digestion so that glucose enters the blood more slowly.

• Byetta, BYDUREON (exenatide), BYDUREON BCise (exenatide extended-release)
• Victoza, Saxenda (liraglutide); also in combination with insulin degludec as Xultophy
• Trulicity (dulaglutide)
• Lyxumia (lixisenatide)
• Ozempic (semaglutide)

Mounjaro (Tirzepatide)

In May 2022, the FDA approved the once-weekly injection, Mounjaro (tirzepatide). Mounjaro is the only dual-acting glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist approved to improve glycemic control in adults with type 2 diabetes in addition to diet and exercise.

Amylin

Amylin is a hormone released by the pancreas at the same time as insulin. It inhibits the secretion of glucagon. Glucagon is another pancreatic hormone that prevents blood glucose levels from dropping too low. Amylin also slows the rate at which food is emptied from the stomach and helps promote a feeling of fullness after eating.

As with insulin, people with type 2 diabetes do not produce normal amounts of amylin. It's believed that replacing amylin helps control blood sugar levels. A synthetic version of amylin called Symlin (pramlintide acetate) was approved by the FDA in March 2005.

Insulin

Type 2 diabetes treatment plans sometimes include supplemental insulin, but not always. Although supplemental insulin is vital to managing type 1 diabetes, it is only necessary for certain people with type 2 diabetes. This typically includes those who:

• Already had very high blood sugar levels when they were diagnosed
• Are very insulin resistant
• Haven't been able to control blood sugar with oral medicine, diet, and exercise

Your insulin regimen will be tailored to your needs. Some people may need to take long-acting insulin in the morning that will work throughout the day. Others will benefit most from short-acting or rapid-acting insulin taken at mealtime. Others may need both.

There are several delivery options for injectable insulin. The most common is an insulin pen. This is a device fitted with a small needle. Other options include:

• A basic needle and syringe
• An insulin pump or patch that is attached to the body

A synthetic form of insulin called Semglee (insulin glargine) is available. This long-acting form can be substituted for the more expensive Lantus (insulin glargine).

There is also an inhalable insulin called Afrezza (insulin human). This type of insulin is faster-acting than other types.

Blood Glucose Monitoring

For people with type 2 diabetes who take insulin, blood glucose monitoring may be essential for a number of reasons. For example:

• It can provide a picture of how well treatment is working.
• It can tell you how your blood sugar levels are affected by food and physical activity.

If you take multiple injections of insulin throughout the day, you will likely need to take a blood sugar reading before meals and at bedtime. If you take only a long-acting insulin, you may just need to test twice a day, before breakfast and before dinner.

Monitoring is done with a device called a blood glucose meter, or glucometer. This device can measure blood sugar based on a single drop of blood taken from a fingertip. Most devices are designed to do single tests, but there are some that provide continuous glucose monitoring.

Bariatric Surgery

If you are very overweight, your healthcare provider may recommend bariatric surgery as part of your type 2 diabetes treatment. This type of weight loss surgery changes the structure of your digestive system.

There are several types of bariatric surgery, but the Roux-en-Y gastric bypass tends to have the greatest effect on blood sugar. During this procedure, the gastrointestinal tract is changed so food bypasses most of the stomach and upper portion of the small intestine.

People with type 2 diabetes with a body mass index (BMI) greater than 35 are candidates for bariatric surgery.

In studies of bariatric surgery performed on more than 135,000 people with type 2 diabetes, the results were significant. Nearly 90% of subjects:

• Had lower blood sugar
• Were able to reduce the dosage of medication
• Experienced improvements in health problems caused by diabetes

What's more, 78% of patients went into remission after losing weight as a result of surgery.

According to the ASMBS, Roux-en-Y gastric bypass can lead to "remission of type 2 diabetes in 80% of patients and improvement of the disease in an additional 15% of patients."

As with any surgical procedure, bariatric surgery has risks. It also requires significant lifestyle changes. People who undergo weight loss surgery are required to follow a specific nutrition plan that's high in protein and limits refined carbs and added sugars. They also must commit to taking nutritional supplements.

Given the potential complications associated with type 2 diabetes, particularly for people who are obese, the benefits of bariatric surgery may outweigh the risks.

Summary

There are many options for managing type 2 diabetes. The first step is usually lifestyle changes like diet and exercise. Quitting smoking is another important way to improve your diabetes symptoms.

When lifestyle changes don't work, there are oral and injectible medications available to help you manage your type 2 diabetes. For some people, daily insulin may be necessary. If you take insulin, you will likely need to monitor your blood glucose levels regularly so you know how well your treatment is working and how your blood sugar levels are impacted by food and exercise. 

For people with type 2 diabetes who have a body mass index greater than 35, bariatric surgery may be an option.