Non-insulin-dependent diabetes - Treating type 2 diabetes

Medicines for type 2 diabetes

Type 2 diabetes usually gets worse over time. Making lifestyle changes, such as adjusting your diet and taking more exercise, may help you control your blood glucose levels at first, but they not be enough in the long term.

You may eventually need to take medication to help control your blood glucose levels. Initially, this will usually be in the form of tablets, and can sometimes be a combination of more than one type of tablet. It may also include insulin or other medication that you inject.

Metformin

Metformin is usually the first medicine that's used 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.

Metformin is recommended for adults with a high risk of developing type 2 diabetes, whose blood glucose is still progressing towards type 2 diabetes, despite making necessary lifestyle changes.

If you're overweight, it's also likely you'll be prescribed metformin. Unlike some other medicines used to treat type 2 diabetes, metformin shouldn't 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's produced by your pancreas. Examples of sulphonylureas include:

glibenclamide
gliclazide
glimepiride
glipizide
gliquidone

You may be prescribed one of these medicines if you can't take metformin, or if you aren't overweight. Alternatively, you may be prescribed sulphonylurea and metformin if metformin doesn't control blood glucose on its own.

Sulphonylureas can increase the risk of hypoglycaemia (low blood sugar), because they increase the amount of insulin in your body. They can also 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're usually used in combination with metformin or sulphonylureas, or both. They may cause weight gain and ankle swelling (oedema). You shouldn't take pioglitazone if you have heart failure or a high risk of bone fracture.

Another thiazolidinedione, rosiglitazone, was withdrawn from use in 2010 due to an increased risk of cardiovascular disorders, including heart attack and heart failure.

Read more about the withdrawal of rosiglitazone.

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 (linagliptin, saxagliptin, sitagliptin and vildagliptin) prevent high blood glucose levels, but don't result in episodes of hypoglycaemia.

You may be prescribed a gliptin if you're unable to take sulphonylureas or glitazones, or in combination with them. They're 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 the section on gliptins, above).

It's injected twice a day and boosts insulin production when there are high blood glucose levels, reducing blood glucose without the risk of hypoglycaemia episodes ("hypos").

It also leads to modest weight loss in many people who take it. It's mainly used in people on metformin plus sulphonylurea, who are obese. A once-weekly product has also been introduced.

Another GLP-1 agonist called liraglutide is a once-daily injection (exenatide is given twice a day). Like exenatide, liraglutide is mainly used for people on metformin plus sulphonylurea, who are obese, and in clinical trials it's 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 isn't often used to treat type 2 diabetes because it usually causes side effects, such as bloating and diarrhoea. However, it may be prescribed if you can't take other types of medicine for type 2 diabetes.

Nateglinide and repaglinide

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

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

Insulin treatment

If glucose-lowering tablets aren't effective in controlling your blood glucose levels, you may need to have insulin treatment. This can be taken instead of or alongside your tablets, depending on the dose and the way that you take it.

Insulin comes in several different preparations, and each works slightly differently. For example, some last up to a whole day (long-acting), some last up to eight hours (short-acting) and some work quickly but don't last very long (rapid-acting).

Your treatment may include a combination of these different insulin preparations.

Insulin injections

Insulin must be injected because if it were taken as a tablet, it would be broken down in your stomach like food and unable to enter your bloodstream.

If you need to inject insulin, your diabetes care team will advise you about when you need to do it. They will show you how to inject it yourself and will also give you advice about storing your insulin and disposing of your needles properly.

Insulin injections are given using either a syringe or an injection pen, which is also called an insulin pen (auto-injector). Most people need between two and four injections of insulin a day.

Your GP or diabetes nurse will also teach a relative or a close friend how to inject the insulin properly.

You can read more about insulin and how to inject it on the Diabetes UK website.

Treatment for low blood sugar (hypoglycaemia)

If you have type 2 diabetes that's controlled using insulin or certain types of tablets, you may experience episodes of hypoglycaemia.

Hypoglycaemia is where your blood glucose levels become very low. Mild hypoglycaemia (a "hypo") can make you feel shaky, weak and hungry, but it can usually be controlled by eating or drinking something sugary.

If you have a hypo, you should initially have a form of carbohydrate that will act quickly, such as a sugary drink or glucose tablets. This should be followed by a longer-acting carbohydrate, such as a cereal bar, sandwich or piece of fruit. In most cases, these measures will be enough to raise your blood glucose level to normal, although it may take a few hours.

If you develop severe hypoglycaemia, you may become drowsy and confused, and you may even lose consciousness. If this occurs, you may need to have an injection of glucagon into your muscle or glucose into a vein. Glucagon is a hormone that quickly increases your blood glucose levels.

Your diabetes care team can advise you on how to avoid a hypo and what to do if you have one.

Other treatments

If you have type 2 diabetes, your risk of developing heart disease, stroke and kidney disease is increased.

To reduce your risk of developing other serious health conditions, you may be advised to take other medicines, including:

anti-hypertensive medicines to control high blood pressure
a statin, such as simvastatin or atorvastatin, to reduce high cholesterol
low-dose aspirin to prevent a stroke
an angiotensin-converting enzyme (ACE) inhibitor, such as enalapril, lisinopril or ramipril, if you have the early signs of diabetic kidney disease

Diabetic kidney disease is identified by the presence of small amounts of albumin (a protein) in your urine. If treated early enough, it may be reversible.

Monitoring blood glucose levels

If you have type 2 diabetes, your GP or diabetes care team will need to take a reading of your blood glucose level about every two to six months. This will show how stable your glucose levels have been in the recent past and how well your treatment plan is working.

The HbA1c test is used to measure blood glucose levels over the previous two to three months. HbA1c is a form of haemoglobin, the chemical that carries oxygen in red blood cells, which also has glucose attached to it.

A high HbA1c level means that your blood glucose level has been consistently high over recent weeks, and your diabetes treatment plan may need to be changed.

Your diabetes care team can help you set a target HbA1c level to aim for. This will usually be less than 59mmol/mol (7.5%). However, it can be as low as 48mmol/mol (6.5%) for some people.

Monitoring your own blood glucose

If you have type 2 diabetes, as well as having your blood glucose level checked by a healthcare professional every two to six months, you may be advised to monitor your own blood glucose levels at home.

Even if you have a healthy diet and are taking tablets or using insulin therapy, exercise, illness and stress can affect your blood glucose levels. Other factors that may affect your blood glucose levels include drinking alcohol, taking other medicines and, for women, hormonal changes during the menstrual cycle.

A blood glucose meter is a small device that measures the concentration of glucose in your blood. It can be useful in detecting high blood sugar (hyperglycaemia) or low blood sugar (hypoglycaemia).

If blood glucose monitoring is recommended, you should be trained in how to use a blood glucose meter and what you should do if the reading is too high or too low.

Blood glucose meters aren't currently available for free on the NHS but, in some cases, blood monitoring strips may be. Ask a member of your diabetes care team if you're unsure.

Diabetes UK also provides further information about the availability of blood glucose test strips (PDF, 195kb).

Regularly monitoring your blood glucose levels will ensure that your blood glucose is as normal and stable as possible. As your blood glucose level is likely to vary throughout the day, you may need to check it several times a day, depending on the treatment you're taking.

In home testing, blood glucose levels are usually measured by how many millimoles of glucose are in a litre of blood. A millimole is a measurement used to define the concentration of glucose in your blood. The measurement is expressed as millimoles per litre, or mmol/l for short.

A normal blood glucose level is 4-6 mmol/l before meals (preprandial) and less than 10 mmol/l two hours after meals (postprandial), although this can vary from person to person. Your diabetes care team can discuss your blood glucose level with you in more detail.

Care standards for diabetes

The aim of treating diabetes is to help people with the condition control their blood glucose levels and minimise the risk of developing future complications.

The Department of Health has set out national standards for NHS organisations and professionals covering diabetes care and prevention. The diabetes national service framework was developed by diabetes clinical experts and diabetes patients. Good diabetes care includes:

awareness of the risk factors for type 2 diabetes
advice and support to help people at risk of type 2 diabetes reduce that risk
access to information and appropriate support for people with type 1 diabetes and type 2 diabetes, including access to a structured education programme, such as the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) or X-PERT Health
an agreed care plan to help all people with diabetes to manage their care and lead a healthy lifestyle, including a named contact for their care
information, care and support to enable all people with diabetes to optimise their blood glucose level, maintain an acceptable blood pressure and minimise other risk factors for developing complications
access to services to identify and treat possible complications, such as screening for diabetic retinopathy and specialised foot care
effective care for all people with diabetes admitted to hospital, for whatever reason

You can read more about diabetes care on the Diabetes UK website.