Type 2 Diabetes Treatment: Types, Benefits, and Side Effects

Treatment of type 2 diabetes is not limited to the occasional visit to the doctor: It includes important types of self-care in addition to regular medical care from doctors and other healthcare providers, such as dietitians and mental health professionals.

Diabetes treatment may include:

• Medication
• Nutrition therapy
• Physical activity
• Lifestyle measures to manage stress and other issues
• Specialist care to prevent and treat complications
• Bariatric surgery

“The cornerstone of all diabetes treatment is a healthy lifestyle that includes diet and exercise,” says Kathleen Dungan, MD, an endocrinologist at the Ohio State University Wexner Medical Center in Columbus. “However, diabetes is a progressive disease, which means that even if you are doing well with a particular treatment, it usually fails over time.”

Thus, Dr. Dungan explains, you may need to have your treatment plan assessed regularly with A1C tests — which measure your average blood sugar level over the previous three to five months — every six months or every three months if your blood sugar levels aren’t on target, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

The latest updates about care for type 2 diabetes can be found in the American Diabetes Association’s 2023 Standards of Medical Care, which lists treatment guidelines related to diabetes, complications, new technology, and more.

Many people with type 2 diabetes start with the oral drug metformin (Glucophage) to help meet their blood sugar level goals. Your healthcare team may recommend adding additional drugs to your regimen, either soon after your diagnosis or months or years later, depending on your situation.

There are currently more than 10 classes of diabetes drugs, each of which helps with diabetes management in different ways. Some diabetes drugs can also help with related metabolic conditions such as obesity and heart disease.

Down the line, your doctor may suggest adding insulin to your treatment plan.

Metformin

Metformin is a pill that can reduce excess release of glucose from the liver, acting as an “insulin sensitizer,” explains Dungan. It’s typically the first-line therapy for people just starting out on their diabetes treatment, and it is often continued even when other therapies are added, she says.

Metformin side effects such as stomach upset and diarrhea are generally minimal, especially when you start with low doses and increase them slowly, Dungan says. She notes that metformin does not cause hypoglycemia (low blood sugar) or weight gain, unlike some other treatments; it also has a long safety record and is relatively affordable.

Sulfonylureas and Meglitinides

Sulfonylurea drugs have also been used for many years to help people with type 2 diabetes control their blood sugar.

These drugs “cause the insulin-producing cells of the pancreas to produce insulin almost constantly, which means they increase the risk of low blood sugar and for weight gain,” says Daniel Einhorn, MD, an internist at Scripps Memorial Hospital in La Jolla, California.

“But they are inexpensive and they are effective, and have been used for a long time,” he adds.

According to the U.S. Food and Drug Administration (FDA), examples of sulfonylureas include:

• Glimepiride (Amaryl)
• Glipizide (Glucotrol)
• Glyburide (DiaBeta)

Per the FDA, another group of drugs that stimulate insulin-producing pancreatic cells, or beta cells, is meglitinides, such as:

• Repaglinide (Prandin)
• Nateglinide (Starlix)

Like sulfonylureas, meglitinides can cause your blood sugar levels to drop too low, the FDA notes.

Alpha-Glucosidase Inhibitors

Alpha-glucosidase inhibitors, such as miglitol (Glyset) and acarbose (Precose), impair the digestion of carbohydrates and can help prevent spikes in blood sugar throughout the day, according to StatPearls.

These medicines are especially useful among people with type 2 diabetes who are at risk of low blood sugar or lactic acidosis.

Note that these drugs can lead to upset stomach, gas, and diarrhea, according to Diabetes.co.uk. They may also lead to low blood sugar levels when taken with other diabetes medications, according to the American Diabetes Association (ADA).

Thiazolidinediones

Another family of type 2 diabetes medication is thiazolidinediones (TZDs), which help with glycemic control and improve your body’s insulin resistance, according to StatPearls.

Using TZDs early in the course of the disease may benefit the pancreas, but there are potential long-term side effects to be aware of, including heart failure, weight gain, and bone density loss.

Pioglitazone (Actos) and rosiglitazone are the only approved TZDs in the United States.

Because TZDs can sometimes affect the liver, your liver function will be monitored closely while you’re on these drugs.

DPP-4 Inhibitors

Another group of drugs is known as DPP-4 inhibitors.

DPP-4 inhibitors block the production of an enzyme called dipeptidyl peptidase 4. Decreasing the production of this enzyme allows the body to release more insulin, according to a review published in 2018 in Diabetes Therapy.

Examples of DPP-4 inhibitors currently on the market in the United States include sitagliptin (Januvia) and saxagliptin (Onglyza), according to the FDA.

These drugs are considered an important addition to the management of type 2 diabetes because they don’t cause hypoglycemia or weight gain, per the aforementioned 2018 research. They may even have a positive effect on your cholesterol levels, according to a previous study.

GLP-1 and Dual GLP-1/GIP Receptor Agonists

The drugs in these families are among the newest options for people with diabetes. Experts agree that they can be extraordinarily effective, but they are also expensive relative to other drugs for type 2 diabetes.

Glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are hormones that stimulate insulin secretion after you eat. In people with type 2 diabetes “this process can become blunted or even be absent,” according to StatPearls, leading to higher blood sugar levels. GLP-1 receptor agonists are drugs that mimic the effect of the first hormone; dual GLP-1/GIP receptor agonists mimic both hormones. The ADA now recognizes drugs in these two families as some of the most effective available for lowering blood glucose and improving other markers of metabolic health.

One feature of these drugs that stands out to experts and patients alike is how they can lead to effortless weight loss. While all drugs within this family are associated with at least modest weight loss, research suggests certain formulations may have an unprecedented effect, particularly semaglutide (Ozempic, Rybelsus) and tirzepatide (Mounjaro). Experts argue that weight loss can have a dramatic positive effect on both glycemic control and cardiometabolic health, as one paper in The Lancet notes.

GLP-1 receptor agonists may also protect against cardiovascular and kidney disease, research shows. (The FDA approved the first dual GLP-1/GIP receptor agonist in 2022, and it’s too soon for scientists to know if it will have the same long-term benefits as GLP-1 receptor agonists.)

The latest recommendations from the ADA identify GLP-1 and GLP-1/GIP receptor agonists as the most effective drugs for people with type 2 diabetes who are seeking weight loss. GLP-1 receptor agonists are additionally listed among the best options for those living with, or at high risk of, atherosclerotic cardiovascular disease.

The drugs in this family are usually injected daily or weekly. Examples of GLP-1 receptor agonists include liraglutide (Victoza), dulaglutide (Trulicity), semaglutide (Ozempic), lixisenatide (Adlyxin), exenatide (Bydureon), and exenatide (Byetta), the FDA notes. One GLP-1 receptor agonist, semaglutide (Rybelsus), is available as a daily pill.

There is only one dual GLP-1/GIP receptor agonist available: tirzepatide (Mounjaro).

Common side effects of GLP-1 receptor agonists include nausea, vomiting, diarrhea, and other gastrointestinal discomfort, according to a past review. More serious risks include low blood sugar levels, but this usually only happens if you are taking another medication to lower blood sugar at the same time, such as sulfonylureas or insulin.

Tirzepatide, the lone dual GLP-1/GIP receptor agonist available, is associated with stomach pain, according to the Mayo Clinic. Less common side effects may include skin issues, difficulty in breathing or swallowing, and a fast heart beat.

SGLT2 Inhibitors

Sodium-glucose co-transporter 2 (SGLT2) inhibitors help lower blood glucose levels by stopping the kidneys from reabsorbing sugar your body creates, according to the National Kidney Foundation. This excess sugar leaves the body through the urine.

The ADA’s latest guidelines indicate that SGLT2 inhibitors are of “intermediate to high” efficacy for lowering glucose; research suggests these pills can lower A1C by an average of 0.5 to 0.8 percent.

While SGLT2 inhibitors are not among the most powerful glucose-lowering drugs, they may have other significant benefits. A review published in 2021 in Cureus notes that SGLT2 inhibitors help prevent the development and progression of cardiovascular disease and kidney disease. As a result, the ADA now considers SGLT2 inhibitors one of the preferred drug treatments for people with type 2 diabetes who have the following characteristics:

• A high risk of atherosclerotic cardiovascular disease
• Atherosclerotic cardiovascular disease
• Heart failure
• Chronic kidney disease

An article published in 2019 in Drugs notes SGLT2 inhibitors may offer modest weight loss.

These pills are typically taken daily, according to StatPearls. There are four SGLT2 inhibitors on the U.S. market today:

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

In addition, several combination pills are available, which combine an SGLT2 inhibitor with another diabetes drug, such as metformin.

The FDA warns that SGLT2 inhibitors can increase the risk for ketoacidosis and serious urinary tract infections. Other side effects may include dehydration, kidney problems generally related to dehydration, increased cholesterol, and yeast infections.

Combination Therapy

Many of the above drugs for type 2 diabetes are prescribed simultaneously to create an even stronger glucose-lowering effect. A number of the most common combinations are also available in a combined form, including glyburide and metformin (Glucovance), as well as sitagliptin and metformin (Janumet).

“There are numerous combination therapies that incorporate most classes of glucose-lowering medication,” Dungan says.

Combination medication can be highly effective and help reduce the pill burden for people with diabetes, she says.

But Dungan notes that one drawback of combination medication is that the dose of the individual medication in each cannot be individually adjusted. In addition, if you experience side effects, it can be tougher to figure out which medication is to blame.

You may need insulin if you cannot meet your A1C goals despite treatment with other types of agents, or if you have severely elevated glucose, Dungan says. You may especially need insulin if you are symptomatic or need to lower your glucose levels quickly.

Some people will need to take one or two doses of long-acting insulin per day, such as insulin glargine (Lantus) or insulin detemir (Levemir), and others will need to take long-acting insulin as well as rapid-acting insulin, such as insulin lispro (Humalog) or insulin aspart (Novolog), before meals, according to the University of California in San Francisco.

“Most patients with type 2 diabetes who require insulin start with a single injection of long-acting (basal) insulin given once daily,” Dungan says. Short-acting insulin may be added later on to get glucose levels further under control. That short-acting insulin, Dungan explains, is generally started with the largest meal of the day, and coverage during additional meals is added as needed.

Weight Loss

Weight management is one of the pillars of diabetes management. Being overweight or obese is highly associated with the progression and development of type 2 diabetes, and weight loss can confer comprehensive metabolic benefits.

The ADA notes that for adults with excess weight, modest weight loss (about 3 to 7 percent of baseline weight, so between 6 and 14 pounds if your baseline weight is 200 pounds) improves glycemic control and can help reduce reliance on glucose-lowering medication. Greater weight loss (more than 10 percent, so 22 pounds or more for an individual who weighs 200 pounds at baseline) can lead to A1C reductions and, in some cases, potentially diabetes remission.

If you have diabetes, having an individualized meal plan focused on managing not only blood sugar but also weight, cholesterol, and blood pressure, as well as any other medical conditions, can help you meet your health goals.

There’s no one-size-fits-all eating plan for people with diabetes. Consider working with a registered dietitian nutritionist (RDN) who is also a certified diabetes care and education specialist (CDCES) to design a diabetes meal plan that meets your diabetes goals and accommodates your food likes and dislikes, daily schedule, and access to food.

People with type 2 diabetes should first think about portion control and maintaining a healthy weight, Dungan says, since weight loss helps with glucose control in people with diabetes, according to Johns Hopkins Medicine.

She notes that working with a registered dietitian to develop a meal plan to fit your lifestyle can be helpful, “since the best diet is the one that a person can stick with for the long haul.” To that end, Dungan notes that keeping a food log can help you understand how many calories, carbs, and nutrients you’re consuming.

In addition, limiting carbohydrates, especially simple carbohydrates, such as white bread, white pasta, white potatoes, white rice, cereal, and juice, can be helpful for people managing diabetes, Dungan says. Those foods tend to cause a fast rise in blood sugar levels. Instead, opt for more fresh nonstarchy vegetables, or high-fiber, whole-grain options, she says, noting that the Mediterranean diet is rich in vegetables, lean meats and fish, and monounsaturated fats, and low in saturated fats and simple carbohydrates. Fruit is also okay in moderation, especially certain choices that are high in fiber, such as berries, apples, and pears. Dungan adds that you can monitor your glucose levels one to two hours after meals to determine how the food you’ve eaten affects your blood sugar. Be sure to check with your doctor before starting any glucose monitoring, so that you can figure out the best mode and frequency for your individual health.

If you haven’t developed a self-care routine involving forms of exercise that you love, now is the time. Getting regular movement can be a powerful tool in your diabetes management toolbox, aiding weight management, helping moderate your blood sugar response, boosting mood, and supporting healthy sleep, among other known health benefits of exercise.

Indeed, the ADA recommends regular physical activity for people managing type 2 diabetes.

Strive to get 150 minutes, or two and a half hours, per week of moderate- to vigorous-intensity aerobic activity, such as:

• Brisk walking
• Climbing stairs
• Playing tennis
• Dancing
• Bicycling or indoor spinning
• Rowing
• Jogging or running
• Hiking
• Skating

The ADA also recommends strength training two to three times per week in addition to aerobic activity. Strength training exercises for people with diabetes (or anyone, really) may include:

• Lifting weights
• Taking group fitness classes that involve using weights
• Using weight machines at the gym
• Heavy gardening or other activities that can help you build and maintain muscle

The organization also recommends breaking up sedentary behavior with three or more minutes of light activity every 30 minutes, according to a previous statement published in Diabetes Care. That light activity may include:

• Overhead arm stretches
• Torso twists
• Leg lifts or extensions

Before you start a formal exercise program or increase your level of physical activity, get your doctor’s okay and find out which activities you can do safely.

If you have uncontrolled high blood pressure, severe neuropathy, foot ulcers, or diabetic retinopathy, you may need to take certain precautions, according to Kaiser Permanente.

In general, though, exercise can provide a lot of benefits. “Exercise is critical for patients with diabetes to maintain heart health and maintain glucose control,” Dungan says. She notes that it’s best to consult your doctor about the type and frequency of activity that is best for you, and find out whether you need additional testing to make sure that exercise is safe. Still, Dungan says, brisk walking nearly every day for at least 30 minutes is safe and beneficial for most people.

Also known as weight loss surgery, bariatric surgery either restricts the amount of food that can be eaten or changes the way nutrients are absorbed in the digestive tract. The result is usually significant weight loss.

In some people with type 2 diabetes and obesity, bariatric surgery has been found to induce diabetes remission. Research published 2019 in Current Diabetes Reports found that bariatric surgery induced remission of type 2 diabetes in 33 to 90 percent of people in the year after surgery.

It’s important to understand there are several types of bariatric surgery — including gastric bypass and gastric sleeve — and that they can vary in invasiveness and effectiveness for treating type 2 diabetes, Dungan says.

“Gastric bypass remains one of the most effective therapies for treating type 2 diabetes,” Dungan says.

Often, the normalization of blood sugar levels happens before significant weight loss, according to the Cleveland Clinic.

The diabetes-reversing effects of bariatric surgery can last for many years, but it is still important for people who once had type 2 diabetes to be monitored for its recurrence and potential complications.

Your first resource for managing type 2 diabetes should be your primary care provider. Dungan notes most patients with type 2 diabetes can rely on their primary care provider alone for treatment. But it’s important for people with type 2 diabetes to also stay up to date on diet and treatment recommendations by coordinating with a CDCES, RDN, nurse, or pharmacist, Dungan says. Their advice will be particularly helpful at the time of diagnosis and periodically over time, such as after the start of insulin therapy, Dungan explains.

As for other healthcare professionals, Dungan notes many diabetes clinics have dietitians, pharmacists, social workers, and mental health specialists on staff, all of whom can contribute to your diabetes management program.

“Each patient’s needs will differ slightly,” Dungan says. For instance, if you can’t control your blood sugar with standard treatments or if you have frequent or severe hypoglycemia, you should consider seeing an endocrinologist, she says. If you develop complications, like heart disease, kidney disease, or foot ulcers, you may need to see specialists who can help with those conditions.

Everyone with diabetes can benefit from an annual visit to an eye care professional who has experience treating patients with diabetes, Dungan says.

“When depression, anxiety, or other mental health problems occur, they often interfere with a patient’s ability to deal with diabetes,” Dungan says. “So it’s important to recognize these disorders and treat them effectively.”

For example, poorly managed stress or mental health disorders may contribute to diabetes burnout and a general lack of motivation to stay on top of healthy diet and lifestyle habits.

Diabetes experts are also beginning to make sleep health a priority in diabetes management. The latest ADA guidelines include a new section on the importance of sleep, noting that inadequate sleep quantity and quality are diabetes risk factors and that sleep disturbances make self-management of diabetes more difficult.

Your doctor or diabetes educator can help improve your emotional well-being, Dungan says. Even if you do not have a diagnosed mental health disorder, you can benefit from talking to these professionals about diabetes-related distress or general life stressors, and to learn about key resources or relaxation techniques to help you manage the disease.

It is important to practice certain self-care habits. The Centers for Disease Control and Prevention lists a number of self-care practices, including:

Take care of your oral hygiene. People with diabetes have a higher risk of gum problems, which can cause blood sugar to rise, making diabetes harder to control.

Check your blood sugar regularly. If your doctor recommends it, good blood sugar management can prevent complications down the line.

Examine your feet. Foot issues like swelling, sores, blisters, and calluses may be a sign of nerve damage caused by diabetes.

Be sure to talk with your doctor about what you can do each day to improve your disease management.

Additional reporting by Stephanie Bucklin.