Medication Therapy

Diabetes is a disorder characterized by high blood glucose levels, and the reasons for these high levels can vary. In Type 1 diabetes[1], the beta cells of the pancreas are attacked in an autoimmune process and cease to produce insulin, the hormone that lowers blood glucose levels. In Type 2 diabetes[2], the combination of insulin resistance[3] and inadequate insulin production by the pancreas results in high blood glucose. (In insulin resistance, the cells do not respond normally to insulin, so glucose remains in the bloodstream rather than entering the cells where it can be used for energy or stored for later use.)

Regardless of the cause of high blood glucose, treatment for diabetes involves taking steps to lower it. That’s because chronic high blood glucose can lead to complications including impaired vision or even blindness, nerve damage[4], and kidney failure.

Healthy eating and physical activity are always components of a diabetes treatment plan. For people with Type 1 diabetes, insulin is always a necessary part of treatment, and it is often used by people with Type 2 diabetes as well. However, people with Type 2 diabetes usually start medication therapy with oral medicines.

Because diabetes is characterized by high blood glucose, and because high blood glucose can cause a number of serious health problems, lowering blood glucose levels is often — understandably — the focus of diabetes treatment. But it shouldn’t be the only one. Both Type 1 and Type 2 diabetes increase the risk of developing a number of cardiovascular problems, including high blood pressure[5], atherosclerosis (stiffening and “clogging” of the arteries), heart attack, and stroke. Therefore, it is not uncommon for physicians to prescribe medicines to lower blood cholesterol and blood pressure, along with drugs to lower blood glucose, for their patients with diabetes.

1. Initiating medication therapy

When a person is first diagnosed with diabetes, his physician chooses which medicines to prescribe based on many factors, including the type of diabetes the person has, his blood glucose level at the time of diagnosis, as well as any other health conditions he may have.

When someone is newly diagnosed with Type 2 diabetes, he is commonly prescribed metformin[6]. Metformin lowers the amount of glucose produced by the liver and improves the cells’ sensitivity to insulin, so that more glucose is moved from the bloodstream to fat, muscle, and other cells. When the combination of metformin and lifestyle changes is not enough to adequately lower blood glucose levels, other oral or injectable medicines can be added to a person’s Type 2 diabetes medication regimen. Generally, these other medicines lower blood glucose in different ways, and the hope is that together, they will be enough to keep blood glucose levels in the near-normal range.

People with Type 1 diabetes are always prescribed insulin therapy upon diagnosis, although the particulars vary from one person to the next. For example, a person’s initial total daily dose of insulin is based on his body weight, then tailored as necessary to account for lifestyle and level of insulin sensitivity (or resistance). Some people learn to take insulin injections using syringes that they fill themselves from vials of insulin. Others are prescribed insulin pens. And some people start immediately on an insulin pump[7], which is a small electronic device that infuses the insulin into the body over the course of the day. The insulin pump can be programmed to meet individual needs for insulin. (Any of these insulin delivery methods may also be used by people with Type 2 diabetes.)

There are also several types of insulin, including rapid-acting insulin analogs, long-acting insulin analogs, intermediate-acting insulin, and short-acting insulin. Which insulin or combination of insulins a person is prescribed depends on what kind of device he uses to administer his insulin (syringe, pen, or pump) and may also depend on what kind of insurance coverage he has for insulin. The newer insulin analogs are typically more expensive than older types of insulin.

2. Participating in your treatment

You are the most important member of your diabetes care team, and your input is necessary to getting your treatment plan right. When your physician prescribes a drug for you, make sure you understand what condition the drug is intended to treat, and what you can expect when you take it. Be sure to also let your physician know about any concerns you have regarding your drug therapy, such as the cost of it, any side effects, your ability to remember to take multiple medicines, or your ability to take or administer the drugs you’ve been prescribed.

Here are some questions to ask your physician:

• Why are you recommending this drug for me?

• Is this drug safe for me to take?

• How do I take it?

• How will I know the drug is working for me? (How long does it take to start working?)

• What sort of monitoring do I need to do when I start this drug?

• What are the potential risks and side effects associated with this drug?

• How do I minimize the side effects?

• Will it interfere with any other medicines I’m taking?

• Is there a generic drug that works just as well?

When you’re starting a drug that must be injected, it is helpful to work with a trained diabetes educator[8] (who could be a physician, nurse, dietitian, pharmacist, or other health-care professional) to learn the proper technique. People with impaired vision or trouble with fine-motor control often benefit from working with an educator or occupational therapist who specializes in those issues.

A pharmacist can be a useful resource for many questions related to drugs and their use. Consider asking your pharmacist if you have questions about the following:

• Whether or not a drug can or should be taken with food

• Whether it’s safe to drink alcohol with the drugs you take

• What to do if you miss a dose of a drug (or drugs)

• Whether the drug might interact with other drugs or with certain foods

• Tools and techniques for organizing your medicines and remembering to take them

• The availability of special packaging, such as easy-open bottle tops, if you have trouble handling your medicine bottles

• The availability of large-print drug labels

• Alternative dosage forms if you have trouble swallowing

• Simplifying your medication plan

If possible, use only one pharmacy so that all of your prescriptions are filled in one place and the pharmacist knows all the drugs you are taking.

3. How your family can help

Having family support for your diabetes care routine in general, and your medication regimen in particular, can make a positive difference. Each person is different in the amount and type of help he wants or needs.

Obviously, children with diabetes need their parents and other caregivers to manage and often administer their insulin or other diabetes drugs. As children mature, they can take over more responsibility for their diabetes care, but they continue to need adult supervision even into their teen years to make sure they are carrying out their self-management tasks as well as learning the skills that will allow them to manage their diabetes independently as adults.

Adults with diabetes may be perfectly capable of managing their medicines alone, but they still may benefit from help and support from their spouse or partner or other family members, either on a routine basis or only occasionally.

Here are some of things you might ask a family member to do to help you manage your diabetes medication regimen:

• Learn about your diabetes medicines, how they work, and what’s involved in taking them.

• Accompany you to medical appointments to learn more, ask questions, and take notes.

• Provide reminders to take pills or injections, refill prescriptions, etc.

• Be willing to pick up items from the drugstore or make phone calls on your behalf to sort out, for example, problems with insurance claims or mail-order pharmacy deliveries.

• Learn how to inject insulin “just in case.”

• Help you compile an accurate list of all of the medicines you use, the reasons you use them, and the doses you take.

Elderly people with diabetes may need more help with their medication regimen (and other parts of their diabetes self care) than younger adults, especially if they become forgetful or have cognitive and/or emotional changes. An elderly person who recognizes that he needs help or is forgetting things can speak to his physician or pharmacist about the difficulties he’s having and ask for suggestions. He might also reach out to relatives who live nearby to help.

When an elderly person doesn’t recognize that he is not caring for himself properly, a family member may need to speak to his health-care providers on his behalf to determine what sort of help is necessary and how it can be provided. It may be that with the provision of written instructions, frequent reminders from a family member, and simple tools such as pillboxes, an elderly person can continue to live independently and provide most of his own diabetes care. Or it may be that more assistance is needed. Two resources that may be of help to family members who wish to help an elderly relative are Eldercare Locator ([9], [800] 677-1116), and the National Alliance for Caregiving ([10]).

4. Hypoglycemia

Family and other household members of a person with diabetes should be aware of the risk of hypoglycemia[11] (low blood glucose) and how to treat it. Hypoglycemia is more likely to occur in people who take insulin or a sulfonylurea[12] drug such as glipizide, glyburide, or glimepiride. The risk is also somewhat higher in those who take repaglinide or nateglinide[13]. The risk of hypoglycemia associated with other oral drugs for Type 2 diabetes is lower, but not zero, and when other oral or injectable drugs are taken in combination with insulin or sulfonylureas, the risk of hypoglycemia is increased. The risk of insulin-induced hypoglycemia is high in people who also inject pramlintide (Symlin).

Signs and symptoms of hypoglycemia[14] include weakness, shakiness, sweatiness or clamminess, rapid heart rate, and possibly confusion. Treating hypoglycemia in a person who is conscious involves giving that person a food or drink that contains carbohydrate. It is generally recommended that a person start treatment with an amount of food or drink that provides 15 grams of carbohydrate, then wait 15 minutes before checking his blood glucose level with his meter to see if it’s back in the normal range. Each of the following provides about 15 grams of carbohydrate: 3–4 glucose tablets, 1/2 cup orange juice, 1/2 cup regular soda, 1 tablespoon honey or syrup, 8 ounces of skim milk.

Anyone who is at risk for severe hypoglycemia should have glucagon[15] on hand for treatment. Glucagon is an injectable treatment that raises blood glucose level. It is sold by prescription only. An adult family member should be trained in advance on how and when to administer glucagon should it become necessary.

One element of your care

Your diabetes medicines are prescribed to help you keep your blood glucose in an optimal range for you. Work with your physician and other members of your diabetes care team to develop a drug therapy regimen that works for you. Involve your family and friends in your care by keeping them informed about your diabetes treatment plan and explaining what they can do to help and support you. And keep in mind that most people’s diabetes medication regimens change over time, so it’s likely yours will too. Use these changes as opportunities to discuss your needs with both your health-care team and your home-support team.

Want to learn more about the role of medicines in treating diabetes? Read diabetes educator Amy Campbell’s eight-part series on diabetes drugs, covering metformin[16], sulfonylureas[17], meglitinides[18], thiazolidinediones[19], DPP-4 inhibitors[20], SGLT2 inhibitors[21], alpha-glucosidase inhibitors[22], bile acid sequestrants and dopamine receptor agonists[23], non-insulin injectable diabetes medications[24], and insulin[25].

  1. Type 1 diabetes:
  2. Type 2 diabetes:
  3. insulin resistance:
  4. nerve damage:
  5. high blood pressure:
  6. metformin:
  7. insulin pump:
  8. diabetes educator:
  11. hypoglycemia:
  12. sulfonylurea:
  13. repaglinide or nateglinide:
  14. Signs and symptoms of hypoglycemia:
  15. glucagon:
  16. metformin:
  17. sulfonylureas:
  18. meglitinides:
  19. thiazolidinediones:
  20. DPP-4 inhibitors:
  21. SGLT2 inhibitors:
  22. alpha-glucosidase inhibitors:
  23. bile acid sequestrants and dopamine receptor agonists:
  24. non-insulin injectable diabetes medications:
  25. insulin:

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