Got questions about navigating life with diabetes? Ask D'Mine! Our weekly advice column, that is, hosted by veteran type 1 and diabetes author Wil Dubois.

This week, Wil is talking medications available for type 2 diabetes other than insulin, and being up to speed to discuss the options with your doctor.

{Got your own questions? Email us at AskDMine@diabetesmine.com}

 

Robyn, type 2 from Pennsylvania, writes:Hi, I read your column about insulin vs. pills. I don't have a problem with the shots, but I have a BIG problem with the weight gain with insulin. I have gained 30 lbs since being on insulin in 3 years. I HATE it and have thought about stopping my insulin just to get the weight off. I have tried to diet, and changed my lifestyle, which I have about 80%. I still just can’t get the weight off, so I want to find out if there is something else, such as pills, that would do the same as insulin, but without the weight gain. I have horrible side effects with Trulicity and that group of drugs so I need something else. Can you give me some ideas I can pose to my doctor? I think doctors sometimes prescribe insulin because it is easy to manage vs. trying different combos of pills. 

 

Wil@Ask D’Mine answers: First off, thank you for reaching out for ideas rather than just throwing the baby out with the bathwater, like many people in your position do! I’m sorry to hear that the insulin put weight on you. This is by no means a 100% side effect, but many people, unfortunately, do have this problem.

It’s also a bummer that Trulicity & company (GLP-1 injectables) give you trouble, as they’re probably the best family of meds for helping T2s. I’m guessing you’ve had diabetes for a while? Having diabetes for a while often slows down the stomach, and the Trulicity-like drugs slow it down further, making comfortable digestion impossible for some diabetes “vets” when using these meds.

Sucks to have diabetes, doesn’t it?

Still, you’re correct that there are lots of ways to curb high blood sugar, and a pile of pills is a legitimate approach. But I have to disagree with you about insulin being the easy way out for the white coats. In my experience, most doctors hate, hate, HATE to start and manage insulin. In fact, for many decades we’ve had a legacy of docs just layering on pill after pill with abandon, simply to avoid prescribing insulin, and at one time insulin was used as a common "baseball bat" to threaten patients into making lifestyle changes. So I think that your doc was being progressive in jumping in with insulin early on. But still, it’s not working for you, and you certainly gave it a fair shake, so I think you’re in a good position to insist on trying an alternate—and pill-based—therapy plan.

That said, however, I am in NO WAY qualified to suggest to your doc which pills to use. Just to give you an idea of how many choices there are, the recently updated type 2 treatment guidelines from the American Association of Clinical Endocrinologists (AACE) list eight different classes of oral agents:

  • Metformin, the oldie but goodie that retains its first-weapon-of-choice status, met has the best blood sugar-lowering punch of any oral diabetes med. It works primarily by keeping the liver from releasing too much sugar overnight, and assists some with after-meal sugar spikes.
  • SGLT2s, which cause the kidneys to recycle less sugar back into the blood, jettisoning the excess glucose instead into the urine.
  • DDP4s, which act on the gut hormone that shuts down another gut hormone that controls insulin secretion. This is the pill that addresses the other side of the equation of the Trulicity-like meds.
  • TZDs make the body more sensitive to insulin. In other words, they're anti-insulin resistance drugs.
  • AGIs that block the absorption of a portion of the carbs from each meal.
  • SUs that stimulate the pancreas to produce more insulin.
  • Colesevelam, a cholesterol drug with a not-fully-understood glucose-lowering side effect which seems to be related to boosting the body’s own anti-glucose systems.
  • Bromocriptine QR, an anti-depressant that has a side effect of increasing insulin sensitivity.

So there are more than a few options. How to figure out what’s best for you?

Well, the guidelines from AACE can be of some help. They were developed by the organization to help primary care docs in the trenches learn the “playbook” of the diabetes treatment experts. The guidelines list meds in preferred order, and give additional guidance on how to layer them on. The guidelines also provide additional tips: Some pills are more effective than others. Some are riskier than others. Some have bad side effects. Some actually have good side effects. Some can help with weight gain, some are neutral, and some—like your insulin—can pack on the pounds.

AACE has separate recipes for what they call monotherapy, dual therapy, and triple therapy. Of course, both insulin and the Trulicity-like meds are included in the battle plans, but it wouldn’t take much imagination on your doc’s part to create a triple therapy oral plan—if that’s what it took.

But will three pills do the trick? I don’t honestly know. If not, would quad therapy or penta therapy equal the blood glucose-lowering power of insulin? In theory, yes. At some point, some magic combination of pills should be up to the task, but I doubt your insurance company would be willing to pay for more than three meds, and with good reason. In addition to the power each pill packs, each oral drug adds its own layer of risk.

Here's a handy chart, too.

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The fact of the matter is that pills seem to have more side effects than injectable meds, and layering pills upon pills creates layers of risk. On top of that, during my not-that-long diabetes career, several blockbuster miracle pills have gone from the standard of care to wouldn’t-use-on-my-worst-enemy status. Late night TV ads from vulture attorneys are usually asking if you or a love one took     (fill in the blank)      pill, not a shot.

And there’s more: When you start mixing a lot of meds, you can get side effects that have never been documented before, as no one studies the effect of taking 8 diabetes meds at the same time. We just don’t know how many of these meds will play in the sandbox with each other.

So what can you and your doc do to up the chances of getting it right with the minimum number of pills? One thing to consider is that when it comes to diabetes, there’s not just one high blood sugar problem to deal with. There are two: Fasting and post prandial. And different meds are better at addressing the underlying causes of either one or the other. As you move from insulin to oral meds, you’ll need to do a lot of testing to see what your native blood sugar looks like. If you can get your doc’s blessing, a brief period of no meds and heavy testing of your blood sugar (like a dozen times a day) can help both of you understand if your diabetes blood sugar problems are more fasting, more post prandial, or an equal mixture of both. Once you understand that, I think it will be easier to match the various options to the blood sugar patterns your diabetes produces. 

The options are kinda mind-numbing, but with so many to choose from, I’ve got my fingers crossed that you'll find the right handful of pills to keep your sugar demons at bay, and your weight where you want it. Thanks for writing, and be sure to let us know how it works out! 

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.