The Biggest Myth About Starting Type 2 Diabetes Drugs
By Hope Warshaw
People have the misconception that taking glucose-lowering medication is a sign of weakness or that it means you are very sick. Early treatment, however, may be the key to keeping you healthier over time.
Few people are excited about starting a new medication to manage a health condition. When a healthcare provider recommends a new drug, pushback is common. “People generally think that medications are dangerous and needing them is a sign of weakness,” says Dr. John Buse, director of the Diabetes Center at the University of North Carolina School of Medicine.
“The misconception people share is that they must be really sick if they need medication,” says Mary Lou Perry, a registered dietitian and certified diabetes care and education specialist at the University of Virginia Health System. To rebut this concept, Perry asks patients: Who is healthier—the person on no medication with glucose, lipids, and blood pressure not at their targets or the person who takes medication and achieves their targets? (Answer: The person achieving their targets is healthier.)
People are also often afraid of the potential side effects, having to fit medications into their routine, and, of course, the cost.
“People often plead for more time before starting a medication to focus on losing weight, eating healthy, and exercising, thinking they can achieve their targets with these tactics,” says Perry. Both Perry and Buse wholeheartedly agree that these lifestyle changes are beneficial, but with highly effective glucose-lowering medications available that support these efforts and add other benefits, waiting to start medication may not be the wisest decision.
A brief history of diabetes medications
Before the FDA approved metformin in 1994, there were just two types of glucose-lowering medications available: insulins and sulfonylureas (drugs that stimulate the beta cells in the pancreas to release insulin). Side effects of both classes of medications are hypoglycemia (low blood sugar) and weight gain.
Fast-forward to today, and there are more than five categories of glucose-lowering medications, from the widely used generic metformin, to the increasingly prescribed SGLT-2 inhibitors (e.g., Jardiance, Farxiga), GLP-1 receptor agonists (e.g., Victoza, Ozempic, Trulicity, Rybelsus), and the dual GLP-1/GIP receptor agonist (i.e., Mounjaro), along with several others.
The newer glucose-lowering medications do not cause hypoglycemia or weight gain when used alone. Several of them have additional health benefits for people with type 2 diabetes. Metformin lowers glucose levels and reduces the progression of prediabetes to type 2 diabetes. SGLT-2 inhibitors and GLP-1 receptor agonists lower glucose levels and reduce the important risks of kidney damage and heart failure. They, along with the GLP-1/GIP drug Mounjaro, also offer substantial help with weight loss.
Making the case for early treatment
Weight gain can set off hormonal and metabolic changes in the body. These changes trigger insulin resistance, which is the inability of most cells to use insulin effectively to move glucose from the blood into the cells to use as energy. The beta cells in the pancreas that produce insulin subsequently go into overdrive. They overproduce insulin with the goal of maintaining normal glucose levels. The result? An abundance of insulin that can’t be used effectively because most of the body’s cells are insulin resistant.
Eventually, glucose levels in the blood may rise high enough to result in either prediabetes or type 2 diabetes. If prediabetes is diagnosed, glucose levels may continue to rise high enough for a diagnosis of type 2 diabetes. “Don’t let the ‘pre’ in prediabetes lull you into inaction,” says Perry.
She also notes that high glucose levels in prediabetes and type 2 diabetes are a big driver for future heart, kidney, eye, and brain damage. The weight gain also causes high blood pressure and abnormal lipid levels (blood cholesterol and fats), which also increase the risk for heart and blood vessel disease.
Unfortunately, most people are unaware that these changes are occurring because the weight gain happens with few other signs and symptoms over many years. Plus, health care providers don’t often raise a caution flag as they should and encourage immediate action other than weight loss. Millions of people spend years with prediabetes that may then progress to type 2 diabetes.
“People are quick to blame and shame themselves for being in this situation, to which I say, it’s not your fault,” says Perry. “Refocus your time and energy on the all-important lifestyle changes and optimal medication choices.”
A personalized approach to care
With this knowledge about the progression of diabetes and the availability of newer effective medications, experts now recommend a “don’t wait, don’t hesitate” approach to care. This message is paired with a focus on person-centered care and shared decision-making, which means that your healthcare provider should partner with you and consider your individual life, lifestyle, needs, and desires.
People who aren’t quite ready to start a medication may need time to think about it. Both Buse and Perry say they give people one to three months to consider their next steps. They encourage people to use this time to make important changes in their eating and physical activity habits, and then observe the effect on their blood work. With new lab results in hand, Buse and Perry use shared decision-making to decide the best next steps. “I only push my patients to take more rapid action, like starting a new medication immediately, when there’s compelling evidence to do so,” says Buse.
Partner with your health care provider to develop a care plan that realistically fits into your life and helps you achieve your target goals over time. Because of the possibility that prediabetes may progress to type 2 diabetes, you and your providers will need to regularly assess how your plan is working and revise it over the years as needed. Of course, along with controlling blood pressure and cholesterol, the best outcome would be to move from prediabetes to no diabetes (i.e., normal blood sugars).
Starting medications for type 2 diabetes
Over the past decade, the go-to glucose-lowering medication to start with for type 2 diabetes has been metformin, beginning with a low dose (500 mg/day) and increasing to 2,000 mg/day as tolerated and needed. (Note: If metformin causes stomach problems, request the extended-release form.)
However, there is consensus now that the newer, more effective medications (SGLT-2 inhibitors, GLP-1 receptor agonists, and the new GLP-1 RA/GIP drug) should be started in people who have or who are at high risk for heart disease, heart failure, or chronic kidney disease. Another benefit of these medications is weight loss.
Talk with your healthcare providers about which, if any, of these medications is best for you. Factor in all the details about your health, medical situation, and lifestyle. “For new-onset type 2 diabetes, I could be talked into any serious plan for lifestyle changes, glucose-lowering medication, or weight loss surgery,” says Buse. “But my guess is that most insurance companies will insist that you start with the much less expensive metformin before trying or adding [one of the] newer medications, which are significantly more expensive.”
Another important point is to not delay adding or changing medications if your current approach is not helping you reach your management goals.
Starting medication for prediabetes
Along with weight loss, more healthful eating, and more physical activity, consider adding a glucose-lowering medication. Although not approved for prediabetes, ask your health care provider about starting on a low dose of metformin (500 mg). Metformin lowers A1C with minimal risk for hypoglycemia, and it’s low in cost.
Research from type 2 diabetes prevention studies show metformin particularly helps to lower glucose and slow disease progression in younger adults; those with a higher BMI (35 or above), higher fasting glucose (110 mg/dL or above), and higher A1C (> 6.0%); and in women who have had gestational diabetes.
“I offer metformin in prediabetes unless a person has a compelling reason to start one of the other medications [because of] obesity, heart failure, and/or chronic kidney disease,” says Buse. “While metformin for prediabetes is not yet considered ‘life saving’…its benefits are broadly being explored for death, disability, cognition, and COVID outcomes.”
Remission of type 2 diabetes
Type 2 diabetes is traditionally described as a progressive disease. Without major lifestyle changes, A1C levels will gradually increase over time, and more medications such as insulin will be required to manage diabetes. Thus, people with type 2 diabetes are often surprised to hear that they may be able to “reverse” their diabetes or put it into “remission.”
Because “reversal” can imply a permanent cure, the more suitable term is “diabetes remission.” This generally means that A1C has been reduced to the level of someone without diabetes (less than 6.5%), and the person has eliminated the need for diabetes medications altogether or has limited their medication to metformin. Although this is not possible for everyone with type 2 diabetes, it is an exciting option for some.
In summary, research has shown that early action, reaching targets for weight, glucose, lipids, and blood pressure, as well as management of other risk factors, can help delay the progression of prediabetes to type 2 diabetes, reverse type 2 diabetes in some people, and keep you healthier over time. “Research shows that managing glucose levels early on can impact the trajectory of diabetes 10 to 15 years down the road,” says Perry.