New Type 2 Diabetes Medications

From the WebMD Archives

Even if you can manage your diabetes now by just eating well and being active, you may need medication someday.

We've come far since the 1920s, when insulin was first used to treat diabetes. There's no magic pill yet, but you have more options than ever before to help control your blood sugar. And more are coming.

Your Kidneys Move Extra Sugar Out

Most type 2 diabetes drugs work by helping your body make insulin or use it better. Some new medicines are different because they don't have anything to do with insulin.

Your kidneys try to keep glucose, a kind of sugar your cells use for energy, out of your pee. Proteins called sodium-glucose transporters (SGLTs) help your kidneys keep glucose in your blood instead of your pee.

But with type 2 diabetes, if your blood sugar level is already creeping up, you don't need the glucose in your body. Pills known as SGLT2 inhibitors turn off one of those proteins so that you pee it out instead.

  • Canagliflozin (Invokana)
  • Dapagliflozin (Farxiga)
  • Empagliflozin (Jardiance)

These drugs have some extra benefits, says John B. Buse, MD, PhD, director of the Diabetes Care Center at the University of North Carolina at Chapel Hill. "You're losing calories through urine, so there is weight loss -- usually about 5 to 10 pounds in 6 to 12 months."

When you take them, you lose a little bit of salt, too, which can help with your blood pressure.

These drugs aren't perfect, he says. "The downside is that, because there is sugar in your nether regions, women have a higher risk of yeast infections, and uncircumcised men can get foreskin infections."

To avoid the risk of dehydration, Buse says that elderly people with kidney disease and people who are taking diuretics, pills that make you pee out extra water, shouldn't take SGLT2 inhibitors.

Another downside in taking SGLT2 inhibitors is that you could run the risk of developing ketoacidosis, a condition where your body produces high levels of blood acids. If this happens you may require hospitalization.

In addition, canagliflozin has led to reduction in bone density in some patients which puts you at risk for bone fractures.

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Inhaled Insulin

The only inhaled insulin on the market is Afrezza. It's fast acting, so you take it only at mealtimes. It comes in 4-unit and 8-unit cartridges that you pop into a small gadget, like the ones people with asthma use. Those with asthma, COPD or who smoke should not use this medication.

"I think Afrezza has a potential role, but a small one, in people with type 2 because of dose requirements," says Zach Weber, PharmD, clinical associate professor of pharmacy practice at the Purdue College of Pharmacy. "If you have to take 20, 30, or 40 units for your dose, it could be impractical." That could mean using as many as 10 cartridges for a single dose.

"For people who are more sensitive to the effects of insulin, where 1 or 2 units makes a difference to you, my concern is that the lowest dose is 4 units," he adds. If you take more insulin than you need, you could lower your blood sugar too much and cause hypoglycemia.

For people who don't have good diabetes control with their longer-acting maintenance insulin, it's an option, Buse says, although he considers it more of a last resort. "But it's all about individual patient decisions. If a patient thinks it's meaningful or finds it helpful, I would support it."

Long Acting Insulin

Insulin degludec (Tresiba) is an injectable form of insulin that lasts up to 42 hours. It is used once daily for type 1 or type 2 diabetes. It also comes premixed with insulin aspart (Ryzodeg 70/30).

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Longer-Lasting Medicines

When you eat, your gut releases a hormone called GLP-1 that tells your body to make more insulin. The effects of natural GLP-1 last only a few minutes. The effects of medications called GLP-1 receptor agonists are similar, but they work much longer.

You need shots of earlier kinds of these drugs, such as exenatide (Byetta) and liraglutide (Victoza), at least once a day. They can last up to 10 hours.

The new drug lixisenatide (Adlyxin) offers a once a day injection option in type-2 diabetes patients.

Other newer drugs last for 7 days:

  • Albiglutide (Tanzeum)
  • Dulaglutide (Trulicity)
  • Extended-release exenatide (Bydureon)

Side effects for all of GLP-1 medications include side nausea, vomiting, and diarrhea.

"The once-a-week doses have an advantage because you take fewer shots," Weber says. The drawback? You could end up with those side effects for a whole week.

What's Next?

A 2015 report by the Pharmaceutical Research and Manufacturers of America notes that drugmakers are working on over 475 drugs for treating diabetes. Many of them are in very early stages of research. Some might be ready in a few years.

Researchers are close to improving drugs called DPP-4 inhibitors, so you only have to take them once a week. They work by allowing your body to keep making insulin. They block an enzyme that breaks down hormones including GLP-1. DPP-4 inhibitors include medications with:

  • Alogliptin (Nesina)
  • Alogliptin and metformin (Kazano)
  • Alogliptin and pioglitazone (Oseni)
  • Linagliptin (Jentadueto)
  • Linagliptin and metformin (Tradjenta)
  • Saxagliptin (Ongylza)
  • Saxagliptin and metformin (Kombiglyze)
  • Sitagliptin (Januvia)
  • Sitagliptin and metformin (Janumet)

Delayed-release metformin is also on the horizon. It targets the gut so people with kidney disease, who shouldn't take metformin, can use it.

WebMD Feature Reviewed by Michael Dansinger, MD on 0/, 016

Sources

SOURCES:

American Diabetes Association: "History of Diabetes."

Cleveland Clinic: "2015 Medical Innovation Summit: Top 10 Innovations for 2012."

Nauck, M. Drug Design, Development and Therapy, Sept. 11, 2014.

John B. Buse, MD, PhD; chief, division of endocrinology, executive associate dean for clinical research, and director of the Diabetes Care Center, University of North Carolina, Chapel Hill.

FDA: "FDA Approves Afrezza to Treat Diabetes."

Medscape: "All About Afrezza: The New Insulin Inhalation Powder," "Exenatide Injectable Suspension," "Albiglutide," "Dulaglutide," "Liraglutide."

Zach Weber, PharmD, BCPS, BCACP, CDE; clinical associate professor of pharmacy practice, Purdue College of Pharmacy, West Lafayette, IN; clinical pharmacy specialist, ambulatory care, Eskenazi Health.

American Academy of Family Physicians: "Diabetes: Insulin Therapy."

The Endocrine Society Hormone Health Network: "Fact Sheet: GLP-1 Receptor Agonists."

Pharmaceutical Research and Manufacturers of America: "2014 Report: Medicines in Development: Diabetes."

Pathak, R. Pharmacy and Therapeutics, September 2010.

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