Diabetes, type 2 - Treatment 

Treatment for diabetes aims to help people with the condition to control their blood glucose levels and minimise the risk of developing complications over time. If you are diagnosed with type 2 diabetes, you will need to look after your health carefully for life. This may seem daunting, but your diabetes healthcare team can offer support and advice about all aspects of your treatment.

Lifestyle modification

For many people who are diagnosed with type 2 diabetes, the first approach to treatment will be making changes to your lifestyle. These include taking regular exercise, eating a healthy diet and losing weight if you are overweight or obese. Doing this may be enough to keep your blood glucose at a safe and healthy level, without the need for other treatment.

Taking medicines

Type 2 diabetes usually gets worse over time. Even if they work at first, diet and exercise may not be enough to control your blood glucose levels.

If you have type 2 diabetes, you may need (or eventually need) medicines that reduce high levels of blood sugar. At first, this will usually be tablets, sometimes a combination of more than one type of tablet. It may also include injectable insulin.

Want to know more?

• Diabetes UK: Treating diabetes.

Blood glucose testing (HbA1c)

If you have type 2 diabetes, your GP or diabetes healthcare team will need to take a reading of your long-term blood glucose level about every two to six months. This shows how stable your glucose levels have been in the recent past and how well your treatment plan is working.

The test that is used to measure your blood glucose levels over the previous 6-12 weeks is known as the HbA1c test. HbA1c is a form of haemoglobin, the chemical that carries oxygen in red blood cells, which also has glucose attached to it.

A high HbA1c level means your blood glucose level has been consistently high over recent weeks, and your diabetes treatment plan may need to be changed. Your diabetes healthcare team can help you set a target HbA1c level to aim for. This will usually be less than 59 mmol/mol HbA1c (7.5%). It can be as low as 48mmol/mol (6.5%) for some people.

Monitoring blood glucose levels yourself

As well as having your blood glucose level checked by a health professional every two to six months, you may also be given the opportunity to monitor your own blood glucose levels.

Even if you are being treated with tablets or insulin therapy and a healthy diet, many factors such as exercise, illness and stress can affect blood glucose levels. Other factors that may affect your blood glucose levels include drinking alcohol, taking other medicines and, for women, changes to hormone levels during the menstrual cycle.

Many people with diabetes monitor their blood glucose levels at home using a simple finger prick blood test. This is to ensure that your blood glucose level is as normal and stable as possible. Blood sugar levels vary from person to person as well as throughout the day, so you may need to do it several times a day, depending on the type of treatment you are taking.

In home testing, blood glucose levels are usually measured by how many millimoles of glucose are in a litre of blood. A millimole is a measurement used to define the concentration of glucose in your blood. The measurement is expressed as millimoles per litre, or mmol/l for short.

A normal blood glucose level is 4.0-6.0 mmol/l before meals (preprandial) and less than 10.0 mmol/l two hours after meals (postprandial), although this can very from person to person. Your diabetes healthcare team can discuss your blood glucose level in more detail with you.

Find out how to test your glucose levels.

If regular exercise and a healthy diet are not effective in controlling your blood glucose levels, you may need medicines to treat type 2 diabetes.

Several different types of medicine, usually taken as tablets, are used to treat type 2 diabetes. You may need to take a combination of two or more medicines to control your blood glucose level.

Metformin

Metformin is often the first medicine that is recommended to treat type 2 diabetes. It works by reducing the amount of glucose that your liver releases into your bloodstream. It also makes your body's cells more responsive to insulin.

If you are overweight, it is likely that you will be prescribed metformin. Unlike some other medicines that are used to treat type 2 diabetes, metformin should not cause additional weight gain. However, it can sometimes cause mild side effects, such as nausea and diarrhoea and you may not be able to take it if you have kidney damage.

Sulphonylureas

Sulphonylureas increase the amount of insulin that is produced by your pancreas. Examples of sulphonylureas include:

• glibenclamide
• gliclazide
• glimerpirizide
• glipizide
• gliquidone

You may be prescribed one of these medicines if you cannot take metformin or if you are not overweight. You may be prescribed a sulphonylurea and metformin if metformin does not control blood glucose on its own.

Sulphonylureas can increase the risk of hypoglycaemia (low blood glucose) because they increase the amount of insulin in your body. Sulphonylureas may sometimes cause side effects including weight gain, nausea and diarrhoea.

Glitazones (thiazolidinediones, TZDs)

Thiazolidinedione medicines (pioglitazone) make your body’s cells more sensitive to insulin so that more glucose is taken from your blood. They are not often used alone, but are usually used in addition to metformin or sulphonylureas, or both. They may cause weight gain and ankle swelling. Do not take pioglitazone if you have heart failure or if you have a high risk of bone fracture.

Another thiazolidinedione, rosiglitazone, has been withdrawn from use because of the increased risk of cardiovascular disorders, including heart attack and heart failure. If you are currently taking rosiglitazone, you should continue to take the medicine as prescribed. You should also make an appointment to see your healthcare team to discuss alternative medication.

Gliptins (DPP-4 inhibitors)

Gliptins work by preventing the breakdown of a naturally occurring hormone called GLP-1. GLP-1 helps the body produce insulin in response to high blood glucose levels, but is rapidly broken down. By preventing this breakdown, the gliptins (sitagliptin and vildagliptin) act to prevent high blood glucose levels, but do not result in episodes of hypoglycaemia. You may be prescribed a gliptin if you are unable to take sulphonylureas or glitazones. They are not associated with weight gain.

GLP-1 agonists

Exenatide is a GLP-1 agonist, an injectable treatment that acts in a similar way to the natural hormone GLP-1 (see section on gliptins, above). It is injected twice a day and boosts insulin production when there are high blood glucose levels, reducing blood glucose without the risk of hypoglycaemic episodes ('hypos'). It also leads to modest weight loss in many people who take it. It is mainly used in people on metformin plus sulphonylurea who are obese (with a BMI of 35 or above).

Another GLP-1 agonist called liraglutide has recently been launched in the UK. It is a once daily injection (exenatide is given twice a day). Like exenatide, it is mainly used in people on metformin plus sulphonylurea who are obese, and in clinical trials it has been shown to cause modest weight loss.

Acarbose

Acarbose helps prevent your blood glucose level from increasing too much after you eat a meal. It slows down the rate at which your digestive system breaks carbohydrates down into glucose.

Acarbose is not often used to treat type 2 diabetes because it usually causes side effects, such as bloating and diarrhoea. However, you may be prescribed acarbose if you cannot take other types of medicine for type 2 diabetes.

Nateglinide and repaglinide

Nateglinide and repaglinide stimulate the release of insulin by your pancreas. They are not commonly used but may be an option if you have meals at irregular times. This is because their effects do not last very long, but they are effective when taken just before you eat.

Nateglinide and repaglinide can cause side effects, such as weight gain and hypoglycaemia (low blood glucose).

Want to know more?

• Diabetes UK: Tablets.

If glucose-lowering tablets are not effective in controlling your blood glucose levels, you may need to have insulin treatment. Insulin treatment can be taken instead of or alongside your tablets, depending on the dose and the way that you take it.

Insulin comes in several different preparations and each works slightly differently. For example, some last up to a whole day (long acting), some last up to eight hours (short acting) and some work quickly but do not last very long (rapid acting).

Your treatment may include a combination of these different insulin preparations.

Insulin injections

In most cases of diabetes, you will need to have insulin injections. Insulin must be injected because if it were taken as a tablet, it would be broken down in your stomach, just like food, and wouldn’t be able to enter the bloodstream.

If you need to take insulin by injection, your diabetes healthcare team will advise you about when you need to take it. They will show you how to inject it yourself. They will also give you advice about storing your insulin and disposing of your needles properly.

Insulin injections are given using either a syringe or an injection pen, which is also called an insulin pen (auto-injector). Most people need between two and four injections a day. Your GP or diabetes nurse will also teach one of your close friends or relatives how to inject the insulin properly.

Want to know more?

• Diabetes UK: Insulin.

If you have type 2 diabetes that is controlled using insulin, you may experience episodes of hypoglycaemia. Hypoglycaemia can occur when your blood glucose levels become very low. Mild hypoglycaemia (a 'hypo') can make you feel shaky, weak and hungry, but it can usually be controlled by eating or drinking something sugary.

If you have a hypo, you should initially have a form of carbohydrate that will act quickly, such as a sugary drink or glucose tablets. This should be followed by a longer-acting carbohydrate such as a cereal bar, sandwich or piece of fruit. In most cases, these measures will be enough to raise your blood glucose level to normal, although it may take a few hours.

However, if you develop severe hypoglycaemia, you may become drowsy and confused, and you may even lose consciousness. If this occurs, you will need to have an injection of glucagon into your muscle. Glucagon is a hormone that quickly increases your blood glucose levels.

Your diabetes healthcare team can tell you how to avoid a hypo and what to do if you have one.

If you have type 2 diabetes, you have an increased risk of developing heart disease, a stroke and kidney disease. To reduce the chance of this, you may be advised to take other medicines which will reduce your risk, including:

• anti-hypertensive medicines to control high blood pressure
• a statin, such as simvastatin or atorvastatin, to reduce high cholesterol levels
• low-dose aspirin to prevent a stroke
• an angiotensin-converting enzyme (ACE) inhibitor, such as enalapril, lisinopril or ramipril, if you have the early signs of diabetic kidney disease

Diabetic kidney disease is identified by the presence of small amounts of albumin (a protein) in your urine. If it is treated early enough, diabetic kidney disease is often reversible.