Standards of Medical Care in Diabetes 2017: Diabetes Medications

Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

I recently reviewed updates to the American Diabetes Association’s (ADA) Standards of Care for 2017.  In this post, I’ll review Section 8 of the standard that talks about different medications for treating diabetes. I will also discuss some of the newer medications used to treat diabetes.

Type 1 Diabetes is always treated with insulin, either through multiple injections or an insulin pump. Type 2 Diabetes can be treated with oral medications (pills by mouth), injections, or both.  The ADA recommends that people with Type 2 diabetes start patients start with the pill metformin, as long as it safe for them to take it.    Taking metformin for a long time may lead to not getting enough Vitamin B12, stomach symptoms, and can affect how well the kidneys work (your care team will monitor your kidneys to be sure they are working properly).

If someone is taking one oral medication at the highest possible dose but their A1C is still not at goal, providers should consider adding additional medications:  another oral medication, long acting insulin (injection), or a non-insulin injectable medication called glucagon-like peptide 1 receptor agonists (GLP-1 receptor agonists).

Examples of GLP-receptor agonists are exenatide (Byetta), liraglutide (Victoza), and dulagultide (Trulicity).  These medications cause food to move through the stomach slower so people feel full sooner. This leads to less glucagon (another hormone made by the pancreas) being released after meals and lowers appetite, which helps with weight loss.  These medications need glucose to work, so there is little chance of hypoglycemia.  Side effects include nausea, vomiting and acute pancreatitis. They may also cause medullary thyroid cancer in animals. It should be noted that these medications are expensive.

People with poorly controlled diabetes and atherosclerotic cardiovascular disease (ASCVD aka heart disease) may benefit from a new medication called empagliflozin (Jardiance), a type of medication called SGLT-2 inhibitor.  These medications work by preventing the body from reabsorbing glucose. This lets more glucose leave the body through urine.  People may have lower blood sugar values after eating and lose some weight.  Studies show empagliflozin helped reduce deaths caused by heart attack, stroke, and cardiovascular disease.  Empagliflozin is the only SGLT-2 inhibitor with these results, but other medications are being studied (liraglutide [Victoza] may have the same results, but other GLP-1 receptor agonists are not used this way).  Potential side effects include hypoglycemia, low blood pressure, dizziness, urinary tract infection, needing to urinate a lot, and increased LDL and creatinine (a waste product filtered out by the kidneys).  Again, these medications are very costly.

There are many medications available for the treatment of diabetes. These standards are general recommendations for medical care.  Always discuss questions about your care plan with your healthcare provider.


Diabetic Nephropathy

By Eileen B. Wyner, NP
Bulfinch Medical GroupEileen W

Diabetic Nephropathy (DN) or kidney disease is a potential complication of Diabetes. It may occur in people who have been living with Diabetes for a long time, as well as in people whose Diabetes is poorly controlled.  All people with Diabetes are at risk for DN but it appears that risk may be higher for people who are of Hispanic, African American, or Native American ethnicity.   

We are born with two kidneys which are responsible for several important bodily functions, the most well known being the making of urine (necessary for the removal of waste products from the bloodstream).  The kidneys also help to control blood pressure by regulating our water and mineral balance (also known as our electrolyte balance), and maintain red blood cell count by signaling the bone marrow to increase production of these cells.  Kidney disease occurs when blood sugars are continually too high. The filter system in the kidneys becomes damaged, allowing small amounts of protein to leak out through the urine. This is a painless condition without any symptoms at first, but over time will lead to high or hard to control blood pressure and lower extremity swelling if not treated.

The first step in preventing DN is maintaining good blood sugar control—the closer to goal you can keep your A1C safely, the better it is for your kidneys.  The next step is getting a microalbumin test when you see your health care provider.  This test checks for the presence of a protein called albumin in the urine.  Albumin is normally found in the blood and filtered by the kidneys; when kidneys are working properly albumin is not found in the urine.  When the kidneys are damaged, small amounts of albumin leak out into the urine.  This condition is called microalbuminuria.  The American Diabetes Association recommends receiving a microalbumin test at diagnosis and at least annually afterwards.

Managing elevated microalbuminuria includes working hard at getting your A1C to goal and starting a medication from the class ACE or ARB.  You may know these medications by their common names:  lisinopril or diovan. These medications are used for blood pressure control and are also a good choice for protecting your kidneys.  You may already be on one of these medications and the dose may need to be adjusted as needed.

Long term complications of DN can increase your chance of developing heart or blood vessel disease. Your kidneys may fail and you may need to start dialysis to filter your blood.  You may even need a kidney transplant. There is no cure for DN, however early identification and treatment can decrease worsening complications. When you go for your next Diabetes appointment, ask your health care provider about a microalbumin test to check your kidney status and start working on preserving it.