Which medication should I take?
Pros and Con of Various Diabetic medications
Metformin:
Metformin is usually the 1st line medication for Type 2 diabetes. This should be avoided in severe congestive heart failure, severe liver disease such as cirrhosis, active hepatitis, severe renal impairment, or if the patient has bad gastrointestinal side effects. It is a perfect drug to use if the patient is overweight or obese. It helps lower insulin resistance.
Advantages: Favors weight loss, inexpensive, low risk of low blood glucose
Disadvantages: GI side effects can be troublesome. Avoid congestive heart failure, renal failure, and liver failure.
Sulfonylurea:
This group of drugs stimulates insulin release from the pancreas.
Advantages: Inexpensive. It is beneficial when blood glucose is elevated after meals.
Disadvantages: Risk of severe hypoglycemia, weight gain. Avoid significant renal insufficiency, liver failure, and be cautious if a person has a sulfa allergy. These drugs sometimes have significant interaction with other drugs.
Thiazolidines:
Drugs in this group are Actos (Pioglitazone), and Avandia (Rosiglitazone). Reduces insulin resistance.
Disadvantages: weight gain, These drugs are avoided in congestive heart failure, severe liver disease, osteoporosis, or osteopenia. Pioglitazone is linked with possible bladder cancer. Rosiglitazone is linked to heart disease/cardiac death.
Advantages: It is a good drug to use if there is evidence of fatty liver, severe insulin resistance, elevated Triglycerides.
DPP-4 inhibitor:
Drugs in this group are Sitagliptin (Januvia), Saxagliptin (Onglyza) and Linagliptin (Tradjenta), Alogliptin (Nesina). These work by decreasing glucagon production and stimulate insulin release from the pancreas (this only occurs when glucose levels are elevated).
Disadvantages: Expensive. These drugs are avoided if there is a history of pancreatitis. There is a small concern of pancreatitis and Pancreatic cancer risk with these medications.
Advantages: It is beneficial if there is postprandial hyperglycemia. It is safe to use in liver disease and renal insufficiency; dose reduction may be necessary with some DPP-4 inhibitors such as Januvia and Onglyza.
GLP-1 Agonist:
Drugs in this group are Exenatide (Byetta, Bydureon), Liraglutide (Victoza), Dulaglutide (Trulicity), Semaglutide (Rybelsus, Ozempic), Lixisenatide (Adlyxin), albiglutide (Tanzeum)
Disadvantages: This group of drugs should be avoided if there is a history of pancreatitis and end-stage renal disease. Also, best avoided if there is any family history of MEN syndrome or Medullary thyroid cancer. There is a small concern of pancreatitis, Medullary Thyroid cancer risk, and Pancreatic cancer risk with these medications.
Advantages: This group of drugs should be considered especially in obese patients, and useful if there is postprandial hyperglycemia. It can be used safely in mild to moderate renal impairment. It is helpful in nonalcoholic fatty liver disease.
SGLT2 Inhibitors:
Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglarto) are an oral inhibitor of sodium-glucose cotransporter 2 (SGLT2). Inhibition of SGLT2 reduces the reabsorption of glucose in the kidney, resulting in increased urinary glucose excretion, with a consequent lowering of plasma glucose levels and weight loss.
Advantage: no hypoglycemia risk, Helps lower weight, Seems to reduce CVD risk, Seems to reduce renal function deterioration in patients with mild renal disease.
Disadvantage: Expensive, increased risk of genital yeast infection/urinary tract infections.
Glinides:
They are non-sulfonylurea agents that stimulate the release of insulin from the pancreas. Drugs in this group are Repaglinide (Prandin), Nateglinide (Starlix);
Advantages: Inexpensive. These drugs are beneficial in renal insufficiency or renal failure since they are short-acting secretagogues. They help lower postprandial hyperglycemia.
Disadvantages: can cause hypoglycemia, need to be taken with each meal.
Alpha glycosidase inhibitors:
Drugs in this group are Acarbose (Precose) and Miglitol (Glycet).
These drugs are very mild agents that work by blocking the breakdown of carbohydrates and impairing the absorption of carbohydrates. They are useful if there is mild postprandial hyperglycemia, especially when the A1c is only mildly elevated. This is a useful class to use if there has been hypoglycemia with other diabetic agents. At high doses, GI side effects such as flatulence can be a problem.
Advantages: Generic available, No risk of hypoglycemia
Disadvantages: flatulence common, Mild diabetic agent
Pramlintide (Symlin):
Advantages: This drug is occasionally helpful, especially if the patient is obese, which may reduce weight. It may help to reduce postprandial hyperglycemia.
Disadvantages: Multiple injections, expensive,
Colesevelam (Welchol):
This drug is useful in people with diabetes who have hypercholesterolemia. It helps reduce cholesterol levels and reduces A1c levels by approximately 0.5%. It is useful in patients with mild postprandial hyperglycemia. It is a mild glucose-lowering agent; it could be used with other diabetic medications, especially if the A1c is only slightly elevated above the goal.
Advantage: no hypoglycemia risk, Helps lower cholesterol
Disadvantage: Expensive, need to take 6 pills daily or Powder mixed in a drink. Mild agent
Bromocryptine (Cycloset):
This is a new agent for diabetes treatment. Mechanism of action not clear.
Disadvantage: Mild agent, Expensive
Advantage: It seems to reduce the cardiac-related events
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