Dr. Ahmad Shahzad
Founder | Lyallpur Diabetes Foundation
Consultant Diabetologist | Educator | Advocate for Preventive Care
Type 1 diabetes, in which the body generates little to no insulin, and type 2 diabetes in which the body grows resistant to insulin or produces inadequate amount, are both chronic conditions that affect the body’s capability to regulate blood sugar. To control blood glucose levels, avoid complications and maintain a higher quality of life, medications are essential. Diabetes therapy needs to be intended to patient’s specific needs, with the help of a healthcare professional who can suggest the safest and most effective medication.
Understanding Diabetes and the Role of Medication
Diabetes is a metabolic disease that affects how the body uses glucose, which is its primary energy source. In type 1 diabetes, the pancreatic cells that produce insulin are accidentally attacked by the immune system, resulting in little to no insulin production.
Type 2 diabetes is the most prevalent kind of diabetes, which occurs due to the body’s inability to produce enough insulin or its resistance to it. Medication is frequently needed in both situations to support the body in controlling blood sugar levels and preventing major side effects like kidney damage, heart disease, and nerve issues.
Lowering A1C values, balancing daily blood sugar, and reducing the long-term risk of diabetes-related health problems are the main objectives of diabetic medication therapy. A key component of successful diabetes control is the combination of lifestyle and medications.
First-Line Therapy: Metformin Explained
What is Metformin?
The first line treatment for type 2 diabetes is generally metformin, an oral drug. Furthermore, it is used to treat gestational diabetes and occasionally helps high-risk patients avoid developing diabetes. Off-label usage of metformin is also possible for diseases such as polycystic ovarian syndrome (PCOS).
How it works
Metformin works through numerous mechanisms to lower blood sugar:
- Inhibits hepatic gluconeogenesis, which lowers the glucose production of liver.
- Reduces the gut’s absorption of glucose.
- Helps tissues use glucose more effectively by enhancing the body’s sensitivity to insulin.
- Activate the enzyme AMP-activated protein kinase (AMPK), which aids in controlling the metabolism of fat and glucose.
These mechanisms result in more stable blood sugar levels, specifically in people whose insulin does not work properly.
Benefits
| Benefit | Explanation |
| Weight neutral | Does not cause weight gain; some may lose weight. |
| Low cost | Available as a generic medication and is inexpensive. |
| Cardiovascular protection | Evidence shows a reduced risk of heart disease and stroke. |
| Fewer episodes of low blood sugar | Compared to other diabetes medications. |
| Wide experience | On the market for decades and well-studied |
Common Side Effects
Although most people tolerate metformin well, some people have side effects, notably gastrointestinal distress, specifically when starting or increasing the dosage.
Very Common:
- Stomach pain
- Loss of appetite
- Diarrhea
- Nausea
- Bloating or gas
Occasional:
- Taste disturbances (metallic taste)
- Headache
Rare but serious:
- Lactic acidosis
- Vitamin B12 deficiency
Due to its neutral effect on weight, low cost, safety, and effectiveness, it continues to be the first choice for many people with type 2 diabetes.
You may also like to read: Tandem diabetes
Oral Diabetes Medications for Type 2 Diabetes
| Class | Examples | Main Mechanism | Noteworthy Benefits | Key Risks/Limitations |
| Sulfonylureas | glipizide, glyburide | Stimulate insulin release | Low cost, strong efficacy | Hypoglycemia, weight gain, CV risk |
| DPP-4 Inhibitors | sitagliptin, saxagliptin | Prolong incretins, ↑ insulin, ↓ glucagon | Weight neutral, low hypoglycemia | Modest efficacy, cost |
| SGLT2 Inhibitors | empagliflozin, canagliflozin | Kidney glucose excretion, ↓ blood glucose | Heart/kidney protection, weight & BP reduction | Genital infections, not for low GFR |
| Thiazolidinediones (TZDs) | pioglitazone | Improve insulin sensitivity (PPARγ agonist) | Effective for IR, some CV/lipid benefits | Weight gain, fluid retention, fractures |
| Meglitinides/Alpha-glucosidase Inhibitors | repaglinide/acarbose | Target postprandial glucose | Flexible dosing, reduce after-metal spikes | Mild effect, GI side effects |
Injectable Medications (Non-Insulin)
| Medication | Primary Benefits | Key Points |
| Liraglutide | HbA1c drop, weight loss, CV risk reduction | Daily injection, CV benefit proven |
| Semaglutide | Largest weight/HbA1c reduction, CV benefits | Weekly injection, available oral form |
| Dulaglutide | HbA1c/weight loss, CV benefits | Weekly injection, robust CV data |
Insulin Therapy for Diabetes
This is a thorough explanation that answers all your questions about insulin therapy for diabetes:
When is insulin necessary?
Type 1 Diabetes: Because the pancreas produces little to no insulin, insulin is always required.
Type 2 Diabetes: Insulin is required in type 2 diabetes when:
- Oral or injectable non-insulin treatments and lifestyle modifications are unable to regulate blood sugar levels.
- Extremely high HbA1c (above 9-10%) or exceptionally high fasting plasma glucose (over 250 mg/Dl) are both present.
- Endogenous insulin is not adequate when pancreatic beta-cell activity gradually declines.
- During gestational diabetes if other treatments fail.
Types of insulin
| Insulin Type | Examples | Onset & Duration | Use/Role |
| Rapid-Acting Insulin | Insulin lispro, aspart, glulisine | Onset: ~10-20 mins; Duration: 3-5 hrs | Taken before meals to control postprandial glucose spikes |
| Short-Acting Insulin | Regular insulin | Onset: ~30 mins; Duration: 6-8 hrs | Also, mealtime insulin but slower onset than rapid acting |
| Intermediate-Acting Insulin | NPH insulin | Onset: ~1-2 hrs; Duration: 12-18 hrs | Basal control, usually 2x daily |
| Long-Acting Insulin | Insulin glargine, insulin degludec, insulin detemir | Onset: 1-2 hrs; Duration: up to 24-42 hrs | Provides steady basal insulin throughout the day and night |
New trends
- With weekly dosing, Icodec, an upgraded form of once-weekly basal insulin, is intended to keep insulin levels constant.
- It seeks to enhance adherence and convenience for those who need long-acting insulin.
- According to preliminary clinical research, it may be possible to manage blood glucose that is as efficient as daily basal insulins while necessitating fewer injections.
- Icodec, generally referred to as insulin icodec, undergoes regulatory assessment and is a significant advancement in insulin therapy, specifically for the treatment of type 2 diabetes, where injecting numerous daily injections can be strenuous.
New & Emerging Diabetes Medications
| Medication/Tool | Type | Key Features & Benefits | Status & Outlook |
| Orforglipron | Oral GLP-1 receptor agonist | Oral delivery, improved glucose control, convenience | Investigation; expected approval near-term |
| CagriSema | Combination therapy (Amylin analog + GLP-1 RA) | Enhanced weight loss and glucose control | Clinical trials; promising results |
| Smart Insulin Pens | Digital health technology | Dose tracking, reminders, data synchronization | Increasing usage; growing integration with diabetes care |
Conclusion
To properly handle your diabetes and prevent major complications, you must be aware of your drug alternatives. Finding the best treatment plan for your unique needs requires close collaboration with your healthcare provider because there are many different injectable and oral medications available, each with unique advantages.
Frequent consultations help guarantee that your therapy stays secure, effective, and in line with your health objectives. For genuinely comprehensive diabetes care, keep in mind that although medicine is essential for blood sugar management, it should always be used in conjunction with healthy lifestyle practices such as a balanced diet, regular exercise, and routine monitoring.