If diet, weight loss, and exercise fail to bring your blood glucose levels within the normal range, your doctor will prescribe either oral anti-diabetic medications, insulin injections, or some combination of the two.

Oral anti-diabetic medication

Most people who have not been able to bring their blood sugar under control by lifestyle changes begin with oral medication. There are a number of such medications, and a large number of clinical trials have proven them effective in many cases. However, each class of the medication works differently and has different possible side effects.

The most common of these effects is hypoglycemia, a condition in which blood sugar drops too low and leaves the patient weak, light-headed, and even faint. It may take a bit of trial and error for you and your doctor to find the medication, or combination of medications, that works best in your particular case and has the least unpleasant side effects. The choices are described below.

• Sulfonylureas (glyburide, glimepiride, glipizide) - Sulfonylureas act quickly and are very effective at lowering blood glucose levels. However, they are prone to cause hypoglycemia.

• Short-acting secretagogues (repaglinide, nateglinide) - Short-acting secretagogues are often best taken before meals because they are very rapid- and short-acting. These medications may also cause hypoglycemia.

• Alpha-glucosidase inhibitors (acarbose, miglitol) - Alpha-glucosidases are designed to reduce the amount of food absorbed by your body with each meal. However, their effect on decreasing HbA1c is small, and they can often cause diarrhea, bloating, and gas.

• Metformin - Often prescribed as a first-line medication, metformin has been used for years and is very effective for controlling glucose levels. Metformin can lower insulin resistance while limiting weight gain. It also does not tend to cause hypoglycemia. However, metformin should not be used by people with kidney failure, heart failure, or liver disease.

• “Glitazones” (pioglitazone, rosiglitazone) - These new medications help to control blood glucose by lowering insulin resistance. The glitazones also help to lower cholesterol levels. However, glitazones need to be taken for weeks before any benefit is seen, and they can cause swelling and weight gain as side effects. They should be used with caution in people with heart failure.

Insulin

Oral anti-diabetic drugs work by encouraging the pancreas to produce more insulin than it normally does. That’s why, for example, oral medications typically don’t help patients with Type I diabetes, whose pancreases are unable to produce insulin at all.

But even in Type II diabetics these medications can effectively overwork and wear out the patient’s pancreas, so that it ends up producing very little or no insulin on its own. When that happens, injections of insulin are needed to replace what the pancreas can no longer make.

Although the daily task of taking regular insulin injections and timing them with your meals is not as easy as taking a few pills, a properly designed insulin regimen can be much more effective at controlling glucose levels for many people. Apart from inconvenience, the primary side effect for most people is modest weight gain.

Insulin plus oral medications

It used to be thought that once patients reached the stage of needing insulin injections they no longer needed to take oral anti-diabetic medications. But new research has demonstrated that combining insulin injections and an oral medication may actually be more effective at helping people control their glucose levels.

Taking both, it turns out, reduces the amount of insulin they need to inject and helps balance glucose levels over the course of the day. However, since insulin combined with some oral medications, such as rosiglitazone and pioglitazone, may increase the risk of fluid retention and possibly heart failure, you should be monitored closely if you take these medications.

Frequently Asked Questions

If I have diabetes, what other kinds of health checks should I have?

In addition to contributing to heart disease, poorly controlled diabetes can compromise other critical systems in your body, and it’s important to keep track of their condition. For example, you should have your urine checked for protein at the time you are diagnosed with diabetes and at least once a year afterward to determine whether you have any kidney damage.

Also, you should have your eyes examined by an ophthalmologist or optometrist trained to screen for diabetic eye disease soon after you are diagnosed with diabetes, and then once a year afterward.

Your feet should be inspected at every routine doctor’s visit, and you should have a complete foot examination at least once a year because a combination of circulatory and nerve damage can make them susceptible to infection and ulceration. To guard against infections, you should receive an annual flu shot and a vaccination against pneumonia at least once in your lifetime.

What is "tight" glucose control?

People with diabetes who are able to keep their glucose levels within the normal or target range over a long period of time are much less likely to develop complications. “Tight” glucose control means adhering closely to the following glucose levels:

• Blood glucose between 90 and 130 mg/dL before meals
• Blood glucose below 180 mg/dL after meals
• HbA1c less than 7% at regular checks every 2 to 3 months.

Controlling your glucose levels this tightly is hard work and requires careful diet planning, the right medications, diligence, and a lot of patience. But by partnering with your doctor to achieve this level of control, and by getting the support of friends and family to sustain it, you will not only feel better, but stay healthier over the long term.

I’ve been diagnose with diabetes. Will I have it for the rest of My life?

Not necessarily. It’s true that for most people having diabetes is like having heart disease: it is a chronic condition for which doctors have yet to find a cure. But some people with Type II diabetes have been able to cure themselves of the disease by losing weight, exercising, and changing their diet.

Insulin resistance, the cause of Type II diabetes, is associated with excess body fat. Decreasing this fat can decrease insulin resistance and, for some people, effectively cure their diabetes.

In rare cases, well-controlled Type II diabetes may even resolve on its own, without much weight loss. In all of these cases, however, patients must maintain the healthy lifestyle that brought about these changes and be vigilant about the possibility of their diabetes returning.

What about pancreas transplants?

Complete pancreas transplants are possible, but typically they are limited to patients with Type I diabetes who have severe kidney disease or for whom insulin therapy has been unsuccessful, resulting in major illness.

Researchers are also investigating the possible benefit of transplanting the pancreatic cells that make insulin, called “islet cells,” from another healthy pancreas, instead of transplanting an entire pancreas. But pancreatic islet cell transplants are still in the experimental phase and probably will not be available for a number of years.

Does taking insulin cause weight gain?

Technically, yes. People who begin to take either oral medications or insulin may gain a few extra pounds: two to six pounds in the case of oral medications and as much as nine pounds in the case of insulin therapy. Most of this weight gain occurs during the first three to five years of treatment and is thought to be simply the regaining of weight originally lost as a result of having untreated diabetes.

This weight gain is small and poses no significant health risk, especially when compared with the immense benefit gained from treating the diabetes and achieving tight glucose control. What’s more, new research suggests that using combination therapy (oral medication plus insulin) may result in less weight gain than using insulin alone.