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 the rest of your life. This may seem daunting, but your diabetes care team will be able to give you support and advice about all aspects of your treatment.

Lifestyle changes

For many people who are diagnosed with type 2 diabetes, the first approach to treatment is to make lifestyle changes. These include taking regular exercise, eating healthily and losing weight if you are overweight or obese (a body mass index of 30 or over).

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 glucose. Initially, this will usually be in the form of tablets, and may sometimes be a combination of more than one type of tablet. It may also include insulin or other medication that you inject.

Want to know more?

• Diabetes UK: Treating diabetes

Blood glucose testing (HbA1c)

If you have type 2 diabetes, your GP or diabetes care team will need to take a reading of your long-term blood glucose level about every 2-6 months. This will show 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 that your blood glucose level has been consistently high over recent weeks, and your diabetes treatment plan may need to be changed. Your diabetes care 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 your own blood glucose levels

As well as having your blood glucose level checked by a healthcare professional every 2-6 months, you may be advised to monitor your own blood glucose levels at home.

Even if you have a healthy diet and are taking tablets or using insulin therapy, exercise, illness and stress can affect your blood glucose levels. Other factors that may affect your blood glucose levels include drinking alcohol, taking other medicines and, for women, hormonal changes during the menstrual cycle.

A blood glucose meter is a small device that measures the concentration of glucose in your blood. It can be useful in detecting hypoglycaemia or hyperglycaemia. If blood glucose monitoring is recommended, you should be trained in how to use a blood glucose meter and what you should do should the reading be too high or too low.

Blood glucose meters are not currently available for free on the NHS but, in some cases, blood monitoring strips may be. Ask a member of your diabetes care team if you are unsure.

Diabetes UK also provides further information about the availability of blood glucose test strips (PDF, 195kb).

Regularly monitoring your blood glucose levels will ensure that your blood glucose is as normal and stable as possible. As your blood glucose level is likely to vary throughout the day, you may need to check it several times during the 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 4-6 mmol/l before meals (preprandial) and less than 10 mmol/l two hours after meals (postprandial), although this can vary from person to person. Your diabetes care team will be able to discuss your blood glucose level with you in more detail.

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 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 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 
• glimepiride 
• glipizide 
• gliquidone

You may be prescribed one of these medicines if you cannot take metformin or if you are not overweight. Alternatively, 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 can also 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 usually used in combination with metformin or sulphonylureas, or both. They may cause weight gain and ankle swelling. Do not take pioglitazone if you have heart failure or a high risk of bone fracture.

Another thiazolidinedione, rosiglitazone, was withdrawn from use in 2010 due to an increased risk of cardiovascular disorders, including heart attack and heart failure.

Read more about the withdrawal of rosiglitazone.

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 (linagliptin, saxagliptin, 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, or in combination with them. 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 the 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 episodes of hypoglycaemia ("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. A once-weekly product has recently been introduced.

Another GLP-1 agonist called liraglutide is a once-daily injection (exenatide is given twice a day). Like exenatide, liraglutide 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, it may be prescribed if you can't 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

Insulin must be injected because if it were taken as a tablet, it would be broken down in your stomach like food and would be unable to enter your bloodstream.

If you need to take insulin by injection, your diabetes care team will advise you about when you need to take it. They will show you how to inject it yourself and 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 2-4 injections of insulin a day. Your GP or diabetes nurse will also teach a relative or a close friend how to inject the insulin properly.

Want to know more?

• Diabetes UK: Insulin.

If you have type 2 diabetes that is controlled using insulin or certain types of tablets, you may experience episodes of hypoglycaemia.

Hypoglycaemia is where 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.

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

Your diabetes care team can advise you about how to avoid a hypo and what to do if you have one.

If you have type 2 diabetes, your risk of developing heart disease, a stroke and kidney disease is increased. 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
• 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 treated early enough it may be reversible.