Diabetes Medications Explained: A Guide for Patients

This episode breaks down the different medications used to treat type 2 diabetes, helping patients better understand their treatment options and how these medications work in the body. From metformin to insulin and everything in between, we'll cover the mechanisms, benefits, and potential side effects of each medication class, empowering you to have more informed conversations with your healthcare provider.

Takeaways

• Diabetes management often requires medication alongside lifestyle changes.
• Metformin is typically the first medication prescribed for type 2 diabetes.
• SGLT2 inhibitors help lower blood sugar by increasing glucose excretion in urine.
• GLP-1 receptor agonists stimulate insulin release and can aid in weight loss.
• Sulfonylureas can cause low blood sugar and weight gain.
• DPP-4 inhibitors are generally well-tolerated and do not cause hypoglycemia.
• Insulin is a critical component of diabetes management for some patients.
• Patients should have open discussions with their doctors about medication options.
• Side effects of diabetes medications can vary and should be monitored.
• Always consult a healthcare provider for personalized medical advice.

Keywords

diabetes, medication, Metformin, SGLT2 inhibitors, GLP-1 receptor agonists, health education, patient care, diabetes management, family medicine, health podcast

Chapters

• 7:20 The Learning Starts

Transcript

Ed Delesky, MD (00:07)
Hi, welcome back to your checkup. We are the Patient Education Podcast, where we bring conversations from the doctor's office to your ears. On this podcast, we try to bring medicine closer to its patients. I'm Ed Delesky a family medicine resident in the Philadelphia area.

Nicole Aruffo, RN (00:22)
and I'm Nicole Aruffo, I'm a nurse

Ed Delesky, MD (00:23)
And we are so excited you were able to join us here again today. We have so many songs about our intern that I would just love to share with the

Nicole Aruffo, RN (00:33)
no, no, no.

Ed Delesky, MD (00:36)
Muffins. Muffins. Maybe there'll be a CD out one day. Like if we really make it big and there's a following, then maybe we could put a CD out there.

Nicole Aruffo, RN (00:37)
good.

Maybe we can like put it behind a paywall.

Ed Delesky, MD (00:48)
But the ridiculous songs that we sing around the house. So let's see. Beautiful day today. It was actually kind of warm and we were. Ali's birthday weekend. So beautiful.

Nicole Aruffo, RN (00:57)
Ollie's birthday weekend. He turned eight.

We took him to the pet store. We took him to the park.

Ed Delesky, MD (01:06)
and he loved every bit of it. He did have a little bit too much fun last night.

Nicole Aruffo, RN (01:10)
Yeah, he did throw up randomly, but he seems fine, so.

Ed Delesky, MD (01:14)
Yeah, it was like a one time thing, seemingly right after dinner. And we were able to go to the Christmas village and check all that out. Notably found Belgian French fries. Those were good. But so they had this setup, right? They had like an order window and they had the pickup window. And it was an interesting way. was an interesting model, at least.

Nicole Aruffo, RN (01:17)
Is that some name?

Ed Delesky, MD (01:40)
You have to be really honest because you go to the order window, you stand there in line, you get what you want, you can have some cheese fries. And then you pay and then head to the back of the pickup line. So we looked at that and we thought that that was fraught with peril.

Well, we stood in the pickup line. We stood in the pickup line for like a couple of minutes and we were like, is this is this the line? But I mean, I'm grateful that we we asked around and they were like, no, no, no. You have to go order first. Yeah.

Nicole Aruffo, RN (02:10)
Well, I think it's because there are so many people there. So to have like two shorter lines instead of one really long one. Is that good? If we had this.

Ed Delesky, MD (02:19)
That is good. Yeah, that is underrated. But

that's been sitting in the fridge for months and that is good.

Nicole Aruffo, RN (02:25)
Hash it over here.

Ed Delesky, MD (02:29)
Well anyway, those fries were really good. They were very, very thin. Inspiring to the... I know! So good!

I mean, you can't hand cut a fry like that.

Nicole Aruffo, RN (02:42)
Well, they didn't hand cut it. They had a potato cutter.

Ed Delesky, MD (02:44)
That's what I'm saying. mean, yeah. Yeah, I like the big wedge cuts that we make. Those are beefy and medium.

Nicole Aruffo, RN (02:47)
like when we make them.

the big wedge cuts because

that's it's just easier to cut. I have made, I have cut them small before.

Ed Delesky, MD (03:03)
I mean like that thin. They were thin.

Nicole Aruffo, RN (03:06)
I feel like I'm up for the challenge.

Ed Delesky, MD (03:09)
You want to hand cut them that thin? Yeah.

Nicole Aruffo, RN (03:12)
Make them tonight. No. Actually, they don't go with dinner tonight. Maybe one day this week. We're having a what am I making?

Ed Delesky, MD (03:18)
What is for dinner tonight?

or so that.

Nicole Aruffo, RN (03:25)
yeah, this like orzo with chicken meatball situation.

Ed Delesky, MD (03:29)
Is there like a base sauce that goes?

Nicole Aruffo, RN (03:31)
Yeah, it's like a parmesan pepper situation. Wow. Yeah, it's gonna be delicious. I think I want to double it up so we have some for lunch tomorrow.

Ed Delesky, MD (03:44)
Thank God. That's awesome. Okay. Let's see. Anything else that I wanted to address? well, we did encounter the weird social experiment of asking someone to take your photo.

Nicole Aruffo, RN (03:55)
a hater.

Ed Delesky, MD (03:57)
Well, yeah, you had nothing to do with it. You didn't have to do it.

Nicole Aruffo, RN (03:59)
Well, yeah, that's because it's a boy job.

Ed Delesky, MD (04:02)
So I just you have to stand around and wait for someone to come by. And I mean, send us a piece of fan mail. You've definitely been in this situation like you covet a photo and you're in this situation and crowd of people. You have to size someone up. You have to find someone who is, you know, seems nice enough that they'll oblige, but also talented enough that they'll take a decent picture. And that's a lot of pressure. Like, what if you don't take a picture that someone wants? They're going to ask again someone else.

I mean, this is a big problem. There should be like a sticker, like a button that says, take pictures of people if you take them for me. Like a community of people.

Nicole Aruffo, RN (04:44)
I mean, I think that's.

like generally how it works.

Ed Delesky, MD (04:51)
Right? What people walk around with a sticker that says like if you

Nicole Aruffo, RN (04:53)
No, just like, you know, the common courtesy. Like, you take a picture of like me and my girlfriend and I'll take a picture of you guys.

Ed Delesky, MD (05:04)
Sure, Yeah, I probably should linger around more if I'm ever asking people. Well, there was that first group that we took the picture for, but they didn't offer to take a picture of us.

Nicole Aruffo, RN (05:18)
Well, we were stuffing our face with cheese fries at the time, so.

Ed Delesky, MD (05:21)
I it wouldn't have been. I mean, that would have been an authentic photo at least.

Nicole Aruffo, RN (05:25)
I thought our picture was authentic.

Ed Delesky, MD (05:28)
No, it was. It was. I'm just saying, like, if one were to capture us in the essence of a photo in that moment, it would have been with us eating cheese fries. Instead, we were all buttoned up, looking great, taking the photo when we wanted to. Anyway, maybe the good people who tune into this podcast that we're so grateful for as they come in to learn more about their health for themselves, a loved one or.

Nicole Aruffo, RN (05:38)
we are.

Anyway

Maybe a neighbor since we have business cards now, whenever we're out and someone asks to take their picture, be like, yeah, I'll take your picture. But and then you give them the business card and you're like, you have to scan this QR code and subscribe to my podcast.

Ed Delesky, MD (06:12)
You do. Yeah. And this is exactly what you have to do.

Nicole Aruffo, RN (06:14)
Or wait, even better, we're really workshopping ideas here. They give you your phone anyway with the camera already open. You scan the QR code and follow, do it real quick and then go back to the camera and.

Ed Delesky, MD (06:27)
That nefarious. But I love it. That's a great idea. I love that. We're going over there tonight. This is guerrilla marketing at its finest. What we're also going to do is we're going to boot up the TikTok soon for some videos to help draw in people to listen and create a blog post account for some of our show notes. I mean, on Substack, this is going to be on our website. You'll be able to find us. And you can sign up for an email to get subscriptions.

Nicole Aruffo, RN (06:34)
my God.

Ed Delesky, MD (06:58)
But all that to say, let's see how far we are. my goodness, seven minutes in. All right, well, here we go.

Nicole Aruffo, RN (07:04)
How did he is?

Ed Delesky, MD (07:07)
Yeah, we're going take it one step at a time. Well, some of those are more important than others. We're going to gloss over some of them. Anyway, so what are we going to talk about today,

Nicole Aruffo, RN (07:08)
Dang.

And today we're talking about diabetes medication options.

Ed Delesky, MD (07:20)
Yep. So this was at some point going to come around as an option for an episode, but we had a loyal listener who not the loyal listener, but one of them who messaged in and said, well, how do you bring down your A1C? That was the question. And we'll do an episode on lifestyle changes that you can do. But the first thing that came to mind was when it comes to diabetes, you usually need medicine. And so that's what we're going to talk about today.

What's the first medicine that we're going to talk about for diabetes?

Nicole Aruffo, RN (07:51)
The first one is.

Probably the most common.

Ed Delesky, MD (07:56)
Yeah,

think it's the most common first one at least.

Nicole Aruffo, RN (08:01)
and lovingly known as Metformin.

Ed Delesky, MD (08:03)
Yep. Also goes by brand name Glucophage, Glumecha. I don't see these as much. Glumecha, Rheomet and Fortimet. They might be some of the extended release versions. This is usually the first medication that's prescribed to people with type 2 diabetes. The way it works is that it enhances the body's response to insulin and lowers blood sugar levels in that way, but does not have a risk of hypoglycemia.

Usually the treatment starts with once daily dosing and usually people try to do it with dinner time. And a second dose usually can be added in the morning later on as directed by whoever's prescribing the medicine. The dose can be increased gradually throughout the course of one to two weeks. And there are some like severe conditions that this medicine shouldn't be used in that people's doctors will probably let them know about. But there's a couple of things.

to think about like people with severe, severe, severe kidney disease, severe liver disease, and maybe people who have like a lot, a lot of alcohol consumption. The big bugaboo about these medicines is that a lot of people don't necessarily love the side effects. I will say that these side effects do go away, and the extended release version actually is able to usually take care of some of those side effects.

So that's also something that isn't more commonly in practice these days. The common side effects that I am kind of dancing around here are some nausea, maybe some diarrhea, some bloating and flatulence, may look like gas. But like I said, these usually get better after the course of a few weeks of treatment. And once things are stable, you can go up and increase the dose as your doctor recommends. What you think about metformin? Got it.

Nicole Aruffo, RN (09:56)
What do I think about?

Ed Delesky, MD (09:57)
Yeah, it's like a really easy medicine. It's Completely honest. I think about it all the time. It's really cheap. Like I tell people, you can literally walk out of that office today, go to the pharmacy, get that medicine, and you can start getting things started that night and get started with treatment.

Nicole Aruffo, RN (10:02)
actually don't think about it.

What happens if someone takes my formant they don't have diabetes?

Ed Delesky, MD (10:22)
Well, sometimes people can use it. Well, I mean, I know what you're getting at here. They like go in the obesity medicine literature. They it can be used to reduce total body weight. I think there were a couple of studies that one small one very large that looked at reducing by about like six to eight percent total body weight, usually when the dose starts to get around like fifteen hundred milligrams. But.

Nicole Aruffo, RN (10:24)
And they just want to be a skinny legend.

Ed Delesky, MD (10:51)
Usually people have diabetes when they take this medicine or they're working with their doctor on weight loss. So Metformin is great and all, but like it's the first line cheapest one, but things are changing a little bit when it comes to diabetes management. And so there are other medications available. If Metformin doesn't get the job done, what's the broad stroke thinking about medications and diabetes?

Nicole Aruffo, RN (11:17)
But you can add another second line medication. Typically, it'll be prescribed if your blood sugar or A1C remains above where you want it for about two to three months. Or it could be added sooner if those levels are significantly elevated. Yeah.

Ed Delesky, MD (11:34)
And sometimes people like these things change. Like people are checking their A1C right probably about every three months unless things are different and people's care changes all the time. Like if one other condition pops up, some of these medicines are actually used for different benefits than just lowering their blood sugar. Like if you have diabetes, you're at increased risk for heart disease or kidney disease. And we know that there are other medicines out there that actually can help with those things specifically.

Yeah. And also sometimes metformin isn't tolerated and like people are just like, I can't, I can't take the diarrhea, the gas, please give me something else.

Nicole Aruffo, RN (12:13)
Okay, tell us about our first second line med.

Ed Delesky, MD (12:17)
Yeah, so the SGLT2 inhibitors, if you have a TV anywhere, you will probably see commercials for medications. mean, people may not know them as SGLT, but medications like Invokana, Jardiance, that's a common one that everyone sees on TV these days, and Farziga. Don't get me started on direct to consumer marketing from pharmacies. But SGLT2 inhibitors, and we said second line, but...

In some recommendations, these may be the first medicine someone chooses. SGLT2 inhibitors lower blood sugar by increasing the excretion of glucose through urine. So the sugar literally comes out through your pee. And there are other medications that this compares to, and it does lower the blood sugar a good bit, but people, like this might be a great choice for people with other conditions. So if someone has heart failure or if they have chronic kidney disease,

these medications are awesome. They've shown benefit for people with these diseases. And so, you know, they may not lower blood sugar as much as other medications that we're going to talk about today or insulin, but they can have a lot of a lot of benefit. Sometimes they also lead to like a little bit of weight loss and a little bit of blood pressure lowering. So these are all really great things. But I'm wondering, like, you know, with any medicine and any new thing that I'm having a conversation with someone about

It's not always just about like all the good, like you're adding something foreign to the body. What are some of the side effects of the SGLT2 inhibitors?

Nicole Aruffo, RN (13:53)
So these guys give a fun side effect that can include genital yeast infections, urinary tract infections, and good old fashioned dehydration.

Ed Delesky, MD (14:03)
Yeah. And what I'll say to this is that like, how much does it happen? And a lot of people have questions about these. Usually I would say that it probably gives about maybe the risk of an extra yeast infection a year and maybe an extra UTI. We know that these medicines reduce the chance that people go to dialysis when they have diabetes and chronic kidney disease. And they also have a lot of good outcomes when it comes to heart failure. And so you have to weigh the benefits of that against.

the UTI or the yeast infection. And so there's an open and honest conversation with a patient of like, hey, you can treat these things like the yeast infection, the UTI, if they become too bothersome where the risk doesn't make sense anymore to take the medicine, then sure, that's a personal conversation between someone and their doctor. But to be honest, like those things do exist. Very, very rarely they do have a side effect. And that's also in the commercials. If you were to listen really closely of a

an infection in the perineum called Fournier's gangrene. There is some rare increased risk associated with these medications as well. once again, as these medicines have become more popular and they go out there, that risk remains relatively low. SGLT2 inhibitors can also increase the risk of something called diabetic ketoacidosis, but without gigantically elevated blood sugars.

It's something to keep in mind. Everyone's looking out for it. I personally haven't seen it in the hospital yet. And I know a lot of people who think it's very, very rare, but it's always in the back of everyone's mind when, someone has diabetes and they come to the hospital and things aren't looking quite right. The other thing with SGLT2 inhibitors, sometimes these days they actually may play in when people are getting procedures. So you may want to ask your doctor about having to pause the medication before an upcoming procedure.

Sometimes the anesthesiologists don't love when this medication is in the system. And so that's another feature of this med. So at the end of the day, this is a once daily medication that is usually very well tolerated. It has a lot of benefit and it has those side effects that we talked about. And like with anything, there's a risk and benefit to analyze with your own personal doctor.

Nicole Aruffo, RN (16:21)
Great. Shall we move on to the next

Ed Delesky, MD (16:25)
I think we shall.

Nicole Aruffo, RN (16:26)
The next one, the next group are the GLP1 receptor agonists.

Ed Delesky, MD (16:33)
Yep. So we've heard about these medications on our podcast here, but in different setting in the setting of management of obesity. But this class of medications actually came around before all of that. And they were used to treat diabetes first. Many of them have different names than the obesity medicine medications. These include names like Ozempic, which actually lives in the diabetes bucket. Ribelsis, which is the oral form. Mounjaro

which is the newer medication, Tirzepatide and Trulicity, which is duaglutide, which is its earlier cousin. All of these medications work. They're injectable medications except for Ribelsis. And what they do is they stimulate insulin release after meals, which is the time that insulin is most in use and in need. And they also slow down the digestive process.

They also change the way that your brain experiences hunger to some degree. They're usually recommended for individuals whose blood sugar isn't controlled on the maximum dose of another medication. So if you're on metformin and isn't working, this may be something that your doctor's thinking about for you. So like I mentioned, these medications are usually once weekly injections and they're pretty well tolerated. They don't cause low blood sugar, which is a big bugaboo when you think about diabetes medication. However,

on a practical side, they can suppress diet and promote an extra feeling of fullness, which may result in some weight loss, but also may kind of tip on the other side and give people some nausea, vomiting, and maybe some diarrhea. Usually the gastrointestinal side effects improve over time. You should have an honest conversation with your personal doctor about if this medication is right for you. There are certain conditions that are called contraindications for this medication, including

a family or personal history of MEN1 syndrome, is a rare thyroid condition, or prior history of pancreatitis may make this medicine less attractive for you. And it's also may cause or promote some gallbladder diseases. So that's also something to be considered as well. And obviously this is not exhaustive and of course not medical advice, but more rather just education about this particular medicine in general. Similar to the SGLT-2 medicines and a lot of medicines,

they also may be asked to be stopped before procedures and surgeries. So obviously a lot to say about the GLP-1 receptor agonists, especially as they relate to diabetes, but all in all, they may help lose some weight, they have cardiovascular benefits, certain ones of them, and are a really solid option that have been around for a long time to treat diabetes. So the reason that we talked about those ones first, just to recap, metformin, SGLT2 inhibitors,

and GLP-1 receptor agonists is that some of these other medications have been used for a very long time, but are also falling a little bit out of favor because unlike the other medications like SGLTs and GLP-1s, those have shown to have cardiovascular benefit. They've shown to have improvement in kidney disease. Some of these other medicines are good at lowering blood sugar, but don't have all those extra things all the time.

and they come with a little bit of extra baggage. So the first one I'm thinking of are sulfonylureas. Glucotrol is a brand name and so is Amaryl is another brand name of common medications used. This, like I said, they've been used for a long time. So sulfonylureas increase insulin production by the pancreas, potentially lowering blood sugar levels by about 20%. They're inexpensive, they are readily available, and they do work.

They have a long history of being used and they're a really reasonable second line agent. The big bugaboo with these is that they can cause low blood sugar and they also sometimes can cause weight gain which people don't love but the low blood sugar thing is a big thing to chase. So honestly these medicines are usually approached carefully in people with kidney disease and usually the shorter acting ones are preferred because they have a lower risk of hypoglycemia.

say it out loud here, we'll have a later episode on hypoglycemia and how to manage it. But those symptoms include sweating, shaking, feelings of hunger, anxiety, maybe even confusion.

Nicole Aruffo, RN (21:03)
Really?

Ed Delesky, MD (21:05)
The biggest tip to take away with sulfonylureas is that to reduce the risk of low blood sugar, people may think about skipping the sulfonylurea dose if they know that they're going to miss a meal, much like you would skip your insulin dose if you also think you're going to miss a meal. And those are the big takeaways. They are very reasonable, they're affordable, they've been around forever, but they may cause some hypoglycemia, but they also do a good job of lowering blood sugar.

Nicole Aruffo, RN (21:31)
Okay, give us a little ditty about the DPP-4 inhibitors.

Ed Delesky, MD (21:38)
Yeah, so these medications go by brand names that people may recognize like Januvia or Anglaiza, Trajenta, Nacina or Galvis. They also work by stimulating the pancreas to increase insulin production in response to food intake, usually offered to people who can't tolerate metformin, but maybe like an insurance way they might not be able to qualify for the SGLT2 inhibitors or GLP agonists.

All of these medicines can be usually be used in combination, but that's specifically for you and your doctor. And generally these medications don't cause hypoglycemia or too many changes in body weight, but rarely they can cause things like joint pain, maybe some pancreatitis and severe skin reactions. But usually pretty affordable, reasonable option to add in. They're an earlier cousin of the GLP medications.

Nicole Aruffo, RN (22:33)
Okay, next little ditty on mclitinides.

Ed Delesky, MD (22:37)
So these go by brand names, Pranden or Starlix. They also work similarly to sulfonylureas. They lower the blood sugar levels, but they work a little bit faster. Usually they're taken right before meals. Sometimes they can be used for people who are allergic to sulfonylureas, but they really aren't usually used for the first line options or second line because they tend to be a little more expensive, maybe not having as much bang for their buck and they're like a multi-day.

multi-time a day dose. So that's about that. Honestly, you don't see these too often given all the other options, but they were around for a long time before.

Nicole Aruffo, RN (23:16)
Okay, what about the thiazoladin and diones?

Ed Delesky, MD (23:20)
That was awesome. Say that three times. He's go by brand names Actos and Avandia. They also this is the name of the game here is increase how the body uses insulin. It's also taken in pill form like other diabetes medications. These are much less common. Like when I see this on someone's med list, I'm like, how long have they been taking it for? Oftentimes these medications cause weight gain. They can cause swelling in the feet and ankles. And like the classic teaching in med school is that like

they also may cause new or worsening heart failure. That was found in the studies and it was small, but obviously that is a serious thing. these are less commonly used and especially now when we have medications that improve heart failure. So you don't need to lower the blood sugar at the expense of the heart. These days with the new medications we have, you can just do both. But if you're seeing things out in the wild, maybe it was a thiazoladinadione. Maybe just keeping it in your...

because it was such a fun name to say. And the last of the medications are like an alpha glucosidase inhibitor. These are pre-course or Glycet. These medications actually work by slowing down how the carbohydrates are absorbed in the intestines and help lower the blood sugar spike after meals. all the there are normally enzymes that are in there that break down the sugar. These medications slow all of that down. And so

They're not as effective as metformin. They're not as effective as sulfonylureas. They often can be associated with side effects like gas, diarrhea, abdominal pain, usually minimized by starting at a low dose. And they're usually taken three times a day with each meal. So this is like a cumbersome medication that may not be as effective as everything that's out there today. I kind of recently just stopped someone who was taking this medication. I was like, we're to start something else because.

There are just better options out there though.

Nicole Aruffo, RN (25:15)
So we have a couple meds that you can inject, a lot of meds that you can take by mouth. And then there's insulin, which we haven't touched on, but I think we're probably going to do another whole episode on it.

Ed Delesky, MD (25:27)
Yeah,

this is a big topic. it's the big bugaboo. I've said that four times today, but it's the heart of the day. People are scared of insulin. They don't like taking insulin. think it's a huge step. It is.

These days, the very specific instances are like if your blood sugar is way out of control or if you're peeing a lot and losing weight, that usually means that your body has run out of insulin. And that's when your doctor really may consider putting you on. Also, there are like a billion other reasons that are personal for each person. But at the end of the day, if someone needs insulin because it's not being made anymore or it's not effective, that's something that may need to happen.

We just wanted to say it here because we're talking about all gigantic umbrella diabetes medicines, but we're going to have at least one episode on just insulin in the future. So stay tuned for that. Any other thoughts? Yeah, so that was a lot of information for this episode. You can refer back to any of these because maybe in your health journey for yourself, a loved one or

Nicole Aruffo, RN (26:34)
a neighbor with diabetes.

Ed Delesky, MD (26:35)
Maybe you come across one of these medications and maybe you want to hear more about a conversation while you're reading online or you want to listen to what we have to say about them. But we are so appreciative that you were able to come back and listen to another episode of your checkup. Please check out our website. Please send us some fan mail, visit our Instagram, maybe try to find us on TikTok or if we're on a sub stack by then, by the time you come around, you might be able to find some of our blog posts, our episode outlines, which have more written word based.

So thank you so much for coming back and until next time, stay healthy, my friends. I'm Ed Delesky Thank you and goodbye. Bye.

Nicole Aruffo, RN (27:11)
I'm Nicole.

Ed Delesky, MD (27:25)
This information may provide a brief overview of diagnosis, treatment, and medications. It's not exhaustive and is a tool to help you understand potential options about your health. It doesn't cover all details about conditions, treatments, or medications for a specific person. This is not medical advice or an attempt to substitute medical advice. You should contact a healthcare provider for personalized guidance based on your unique circumstances. We explicitly disclaim any liability relating to the information given or its use.

This content doesn't endorse any treatments or medications for a specific patient. Always talk to your healthcare provider for a complete information tailored to you. In short, I'm not your doctor. And make sure you go get your own checkup with your own personal doctor.

Nicole Aruffo, RN (28:01)
I am not your nurse.