Over the past ten years, more drugs have been marketed to treat diabetes. This is a good thing. However, the newer agents are enormously expensive and beyond the reach of many patients. There is insurance coverage for many of these drugs, but over time the amount of out-of-pocket expense for patients has been increasing.
Diet and exercise are the first "drug" to manage Type 2 diabetes. Often patients have gained weight over time, and weight loss makes management easier. Since diabetes is a risk factor for heart attacks and stroke, it is important to pay attention to blood pressure control, cholesterol levels, and smoking, which add to the risk. Doctors will set lots of goals in a diabetic treatment plan. There are goals for weight, blood pressure, and cholesterol levels. In addition, there are measures for blood sugar control (the defining abnormality in diabetes).
The main measures are fasting blood sugar, after-meal blood sugars, and glycohemoglobin (also called A1C) levels (a measure of the 90 days average blood sugar). I like to think of red cells as little donuts that have a sugar glaze on them. The higher the average blood sugar level, the thicker the sugar coating on the red blood cells. The higher the A1C level, the more poorly the diabetes is controlled. We set individual blood sugar goals, considering patient factors and preferences.
The first drug we use for Type 2 diabetes is Metformin. It is, in general, a very good drug. The main side effect patients have is loose stools. This seems to get better over time. Also, it is helpful to start with a low dose and gradually build towards a higher dose. If there is a significant kidney problem, the dose must be reduced. Or, in some cases, Metformin can not be used. Metformin is not an expensive drug and should be manageable for most patients. Mark Cuban Cost Plus Drug Company sells 30 tablets of Metformin for $3.90!
There are quite a few options for Diabetes treatment beyond Metformin. Unfortunately, here is where the costs escalate. I wish I could tell you that medication coverage through insurance was not confusing. The big companies that manage the pharmacy benefits, like Caremark CVS or Express Scripts, or Part D Medicare programs, all have strategies to control costs. Drugs are placed on Tiers and subject to copays & coinsurance. We pay the copay or a coinsurance amount. GoodRX lists the actual cost of many medications. Because many of us have Prescription Drug coverage, we may not feel the full costs of prescriptions. Some of us with high deductible plans or no insurance do experience these high costs. For example, Januvia is up to $650 for 30 pills. Victoza is up to about $1300 for three pens. Invokana is about $680 for 30 pills.
Second-line drugs for Type 2 diabetes include GLP1 Agonists like Trulicity, Victoza, or Ozempic. Another family of second-line drugs is called Sodium-Glucose Cotransporter 2 Inhibitors (SGLT-2 Inhibitors).
GLP 1 agonists are similar to incretin hormones that are naturally occurring compounds.
The GLP1 agonists do a few things. They cause the pancreas to release insulin in response to elevated blood sugar levels. These are pretty smart drugs and do not cause the pancreas to release insulin when the sugar is not elevated. This lessens the risk of low blood sugar. They also delay stomach emptying. This means patients are less inclined to overeat. These medications seem to reduce the risk of heart disease, stroke, and Diabetic Kidney Disease. The drugs need to be injected, with the exception of a pill called Rybelsus.
The SGLT-2 inhibitors block glucose absorption in the kidney and promote loss of sugar from the kidneys to lower blood sugar. These drugs reduce the risk of heart disease and diabetic kidney disease as well.
Another second-line class of drugs is called Dipeptidyl Peptidase 4 inhibitors (DPP-4 inhibitors). DPP4 inhibitors are taken orally, and they reduce the breakdown of naturally occurring incretins (GLP1-like hormones). Drugs in this class include Januvia, Tradjenta, Onglyza, and Nesina. These drugs cost about $550 without insurance.
The next two classes of drugs are not often used simply because the newer drugs have a variety of advantages.
The Thiazolidinediones increase the effects of insulin on muscle and fat. The trade names are ACTOS and Avandia. These drugs can cause fluid retention and worsen heart failure symptoms. They are not often used.
The secretagogues are an older group of drugs that stimulate insulin release from the pancreas. These drugs stimulate insulin release even when the blood sugars are not elevated. That puts patients at risk for low blood sugar. Over time these drugs tend to lose effectiveness. The advantage of this group of medications is that they are not expensive. They are available as generic products and can still be used if other alternatives are too expensive. There are no benefits for cardiovascular disease or diabetic kidney disease. Some representatives are AMARYL, Glucotrol, and Micronase.
Insulin was discovered by Banting and Best at the University of Toronto in 1921. Charles Best was a graduate student at the time. I had the honor of meeting Dr. Best in 1977 at The Banting and Best Institute in Toronto while in graduate school. Banting viewed insulin as a gift to the world and did not seek to benefit financially from the discovery. I often wonder how he would react to the high price tag of modern insulins. There are a variety of insulins available currently. The insulins are classified as short-acting or basal insulins. The pancreas normally releases a basal level of insulin that provides for basal metabolic needs. The pancreas also releases spikes of insulin around meals. The long-acting insulins have gotten progressively better over time and maintain fairly stable levels of insulin over 24 hours (called peakless). Rapid-acting insulins are given before meals to prevent unhealthy elevations of blood sugar. Insulin is used differently based on the disease stage and the particular care goals for each patient. In general, long-acting insulins are the first ones given to a patient when insulin is started. The most aggressive programs combine long-acting insulin with short-acting insulin before each meal. Older insulins are still available and are less expensive options for those without prescription drug insurance.