Medication
KEY POINTS
There is a wide range of medications available to help you manage your diabetes
For people with Type 2 diabetes, having healthy blood pressure levels is as important as having healthy blood glucose levels
Virtually all people with Type 2 diabetes come to require medication
Testing your own blood glucose levels will help you get onto the right dose of medication to lower your blood glucose levels
If diabetes tablets stop working well enough, insulin can always be added to help you manage your blood glucose levels
If your body weight goes down, or your level of physical activity goes up, you may find the medication you are on for blood glucose or blood pressure will need to be reduced
Recent research has proved that having healthy blood glucose and blood pressure levels greatly reduces the chance of you getting diabetes complications. Developing the complications of diabetes is a process. If you have the early signs of diabetes complications, achieving healthy blood glucose and blood pressure levels may slow down or even halt the progress.
Sometimes people feel as though they have ‘failed’ in their diabetes management if they need to go onto medication. However, Type 2 diabetes is a process. Virtually everyone with Type 2 diabetes at some stage needs medication to help them manage their diabetes.
Tablets
Currently there are four main groups of tablets available in New Zealand that can help lower your blood glucose levels. These groups of tablets work in different ways.
Biguanides
There is only one biguanide tablet, called Metformin but it is also marketed under the name of Metomin or Glucophage.
This tablet works by making your body cells and muscles more sensitive to the action of insulin. It does not make your pancreas make more insulin. This means if you are only taking Metformin (and not insulin or sulphonylurea tablets) for your diabetes, you are not at risk of having low blood glucose levels.
Metformin tends to work best for people who are overweight. This is because people who are overweight tend to have muscles and cells that don’t respond very well to the action of insulin.
Metformin should only ever be taken with food. If you take it on an empty stomach it can make you can feel nauseous.
If you are starting on Metformin it is best for you to start on one tablet only per day, then build up to the dose you need gradually over the next few weeks. If you start on a large dose straight away, it can cause you to have diarrhoea and/or nausea.
If you are on Metformin , and you get an illness that causes you to have vomiting or diarrhoea, you should stop taking your Metformin until you are well again.
SGLT 2 inhibitors
These are a preferred second line agent in Type 2 diabetes with cardiovascular and/or renal disease, and can also be used second line in other people with Type 2.
Empagliflozin is the only funded SGLT 2 inhibitor in New Zealand, is available fully funded for the treatment of people with type 2 diabetes who are at high risk of cardiovascular disease or have renal complications, including all Māori and Pacific peoples. It is available as a stand-alone (Jardiance) or in combination with Metformin (Jardiamet).
They work by reducing glucose levels through increased urinary excretion of glucose and sodium. This can lead to a reduction in your blood pressure and your weight. However, this can also increase your risk of urinary tract infections or yeast infections.
Healthy eating is always encouraged in patients with type 2 diabetes however if you are taking empagliflozin and are considering going on a low carbohydrate diet it is important to discuss this with your medical team first.
Empagliflozin:
can reduce mortality from cardiovascular events and renal disease progression independent of effects on glycaemic control
can lead to weight loss and blood pressure reduction
will not cause hypoglycaemia.
If you are on empagliflozin and you get an illness it is important to discuss this with your doctor. If you have nausea, vomiting or abdominal pain you will need to have your ketone levels checked promptly. This is able to be done at your medical centre, after hours clinic or at the hospital.
DPP-IV (or DPP-4) inhibitors
Vildagliptin is the only funded DPP-IV inhibitor in New Zealand. It is available alone (Galvus) or in combination with Metformin (Galvumet).
DPP-IV (or DPP-4) inhibitors work by keeping hormones released after eating remaining in your body for longer, this increases insulin secretion and decreases glucagon secretion (that increases blood glucose). DPP-IV inhibitors will not cause hypoglycaemia when used alone, however if you are taking insulin or sulfonylureas your risk of hypoglycaemia may be higher.
If you have been told to take one dose of vildagliptin each day, take it in the morning. If you have been told to take two doses each day, take your first dose in the morning and the second dose in the evening. You can take the vildagliptin with or without food.
Swallow your tablets whole, with a drink of water.
Limit alcohol while taking vildagliptin . Taking vildagliptin and alcohol may affect the control of your blood glucose.
If you miss a dose take it as soon as you remember that day. But if it is nearly time for your next dose, just take the next dose at the right time. Do not take two doses at the same time.
Keep taking vildagliptin regularly. Do not stop taking vildagliptin suddenly; speak to your doctor or nurse before stopping.
Vildagliptin usually only causes mild side effects such as nausea, headaches and dizziness. However if you experience any signs of problems with your pancreas or liver such as persistent and severe stomach pain, yellowing of the skin and/or eyes, itchy skin, pale bowel motions or dark urine it is important to speak to your doctor immediately.
Sulphonylurea tablets
These tablets work by making your pancreas produce more insulin. They will only work if your pancreas is actually able to make more insulin. For this reason some people find that these tablets work well for them earlier on in their diabetes, but there comes a time when they no longer work so well.
Sulphonylurea tablets sometimes don’t work very well in people who are overweight. This is because being overweight can make your body resistant to the action of insulin. (insulin action)
There are currently three types of sulphonylurea tablets available:
Gliclazide
Glipizide
Glibenclamide
Sulfonylurea medications should be taken with food. Gliclazide can be taken immediately prior to eating. Glipizide and glibenclamide work best if you take them 15-20 minutes before your meal. However if you have forgotten to take them before your meal, take them with the meal. Gliclazide works just as well if taken closer to your meal, or even with your meal. If you have forgotten to take a dose and remember later in the day, skip this dose and continue with your next dose.
These tablets do increase the chances of your blood glucose level going low. So it’s important not to skip your meals when you take sulphonylurea tablets. You also need to learn about low blood glucose levels (hypoglycaemia), how to avoid them, how to recognise them and how to treat them.
Because sulfonylureas cause more insulin to be released it is important to seek medical help if you get low blood glucose while taking these medications as it will cause your pancreas to continue to release insulin even when you are treating the low blood glucose causing a prolonged effect.
Alpha-Glucosidase inhibitors
At present there is only one drug from this class available in New Zealand, called acarbose. It works by slowing down and reducing the breakdown of complex carbohydrates (starches) into glucose in your stomach and gut. Like metformin it’s best to start on a low dose of acarbose and build up the dose slowly over the next few weeks as it can cause a lot of wind. It is best to take your acarbose at the start of your meal.
Acarbose alone is unlikely to cause low blood glucose. However if you do get low blood glucose while taking acarbose with other diabetes medications such as insulin or sulfonylureas you will need to treat your low blood glucose with glucose tablets. Taking regular sugar, juice or soft drinks will not be as effective as the acarbose will slow the absorption of the sugars. Give the glucose tablets at least 5-10 minutes to be absorbed before taking more complex carbohydrate. This is because the acarbose slows down the breakdown of complex carbohydrates into glucose in your gut.
Sub-cutaneous injection
Insulin
Most people feel afraid if they need to go onto insulin. But the vast majority of people with Type 2 diabetes are surprised at how well they manage on insulin. Once they are on insulin many people feel much better and have a lot more energy.
Insulin needles are now very short and extremely fine. The injection goes just under your skin (not into a vein). Nearly everyone finds that the injection is fairly painless. Most people find having an insulin injection much more comfortable than doing finger pricks. Keeping the insulin vial or pen you are currently using at room temperature can also help to keep the injection painless.
Going onto insulin nearly always leads to your blood glucose levels coming down. This is because the extra insulin is helping your blood glucose to move into your muscles and cells where it can then be burnt up to give you energy. This explains why most people find that they have more energy once on insulin.
When you have Type 2 diabetes and you go onto insulin, you are generally taking this insulin to supplement your own body’s insulin production. People with Type 1 diabetes, however, are dependent on insulin to survive. This is because they either have no insulin at all of their own, or very little.
People with Type 1 diabetes are ‘insulin dependent’ (if their insulin injections are stopped it is life threatening). However, people with Type 2 diabetes who are on insulin are ‘insulin requiring’. They require insulin to manage their blood glucose levels. If the insulin is stopped they may become unwell, but this is generally not life threatening (because they still have some of their own insulin).
GLP-1 receptor agonists
Dulaglutide (Trulicity) is the only funded GLP-1 RA under special authority for high risk people and is injected weekly.
Dulaglutide is funded for people with HbA1c levels > 53 mmol/mol who are at high risk of, or with established, cardiovascular disease, diabetic kidney disease, heart failure or who are of Māori or Pacific ethnicity.
Dulaglutide mimics one of the hormones released when you are eating. This increases insulin secretion when consuming glucose and decreases glucagon secretion (that increases blood glucose) and slows gastric emptying. This can lead to weight loss as well as improved diabetes control.
Because dulaglutide relies on you to be eating to have an effect, there is a low risk of dulaglutide causing your blood glucose to go too low. However if you are taking other diabetes medications such as insulin or a sulfonylurea your risk may be increased.
Dulaglutide reduces mortality from cardiovascular events and renal disease progression independent of glycaemic control. It can cause weight loss and reduce blood pressure, and will not cause hypoglycaemia.
If you are on dulaglutide, and you get an illness that causes you to have vomiting or diarrhoea, you should stop taking your dulaglutide until you are well again.