Type 2 Diabetes: Management, Medications, and Treatment Options

Type 2 diabetes (T2D) is a metabolic condition in which the body’s cells don’t know how to properly use insulin (known as insulin resistance). As a result, sugar builds up in the blood, leading to symptoms such as feeling extremely hungry, frequent urination, and extreme fatigue.¹ If left untreated, T2D can lead to other health complications such as eye damage (diabetic retinopathy), kidney damage (diabetic nephropathy), and nerve damage (diabetic neuropathy).²

Fortunately, doctors and researchers have developed new treatments in recent years to help manage blood sugar levels and make cells more sensitive to insulin. T2D can also be managed by making diet and lifestyle changes. Together, this combination of treatments has helped many people live with T2D and lead a healthy life.

Medications for Treating Type 2 Diabetes

There are several different classes of medication used to treat T2D, each with its own way of treating the condition. Some medications stimulate the pancreas to make more insulin, while others help cells and tissues become more sensitive to insulin.

Overall, these medications help lower blood sugar levels, reducing the risk of further health complications. Your doctor will discuss the best treatment options based on your specific T2D case, taking into consideration any other health conditions you have.

Treating Low or High Blood Sugar Levels

Medications that affect blood sugar levels may cause extremely low levels (hypoglycemia) or extremely high levels (hyperglycemia). With this, it’s important to know the signs of each so you can treat yourself when needed.

Blood sugar levels are considered to be low when they’re below 70 milligrams per deciliter (mg/dL) of blood. Signs of hypoglycemia include:³

• Shaking
• Sweating
• Rapid heartbeat
• Confusion or irritability
• Increased hunger
• Dizziness
• Anxiety or nervousness

If your blood sugar level drops extremely low, you may begin to feel weak, have trouble seeing clearly or walking, and may have seizures. To help treat low blood sugar, the Centers for Disease Control and Prevention (CDC) recommends checking your blood sugar level — if it is between 55 to 69 mg/dL, eat 15 grams of carbohydrates, then check your level again 15 minutes later.

Blood sugar levels are considered to be high when they’re above 125 mg/dL while fasting, or 180 mg/dL one or two hours after eating. Signs of hyperglycemia include:⁴

• Increased thirst and/or hunger
• Blurry vision
• Headache
• Frequent urination
• Weight loss
• Feeling fatigued, tired, or weak

If your blood sugar level rises too high, you may develop diabetic ketoacidosis (DKA).⁵ Though more commonly associated with type 1 diabetes, you can develop DKA from type 2 diabetes. DKA occurs when you don’t have enough insulin to help your cells use glucose (your body’s preferred form of sugar) in the blood. This causes your body to break down fats in your liver for energy, creating ketones. The buildup of ketones in the blood can make it too acidic, leading to symptoms of DKA.

Symptoms of DKA include:

• Urinating more than usual
• Increased thirst
• Flushed face
• Fruity-smelling breath from the buildup of ketones
• Nausea or vomiting
• Stomach pain
• Headache
• Dry mouth and skin
• Stiff or achy muscles
• Extreme fatigue

If you begin to notice any signs of DKA, seek medical attention immediately. If left untreated, it can be a life-threatening condition. You’ll receive insulin, fluids, and electrolytes to help lower your blood sugar level and replenish the minerals your body needs.

Insulin to Manage Type 2 Diabetes

Insulin is a vital hormone that your body needs to help cells use glucose. Insulin is naturally made by beta cells in your pancreas. However, in T2D, the pancreas works overtime to make insulin to help lower blood sugar levels. As the condition progresses, your cells become resistant to insulin and no longer use it properly to use glucose from your blood.⁶ Your pancreas can’t meet the demand for insulin that your body needs, so your blood sugar level continues to rise.⁷

People with severe cases of T2D that can’t be managed with other medications are usually given insulin therapy. There are several different types of insulin that can be used, depending on how quickly the insulin works and stays in your body. Your doctor will likely start you on a “basal” form of insulin, which is usually long-acting to help control your blood sugar throughout the day. Basal insulins are injected once daily in the morning or evening. You may use a pre-filled insulin pen or a needle and syringe to administer the medication.⁸

Examples of intermediate- to long-acting insulins include:

• Insulin isophane suspension (Humulin® 70/30)
• Insulin NPH (Humulin® N)
• Insulin aspart protamine (Novolog® Mix)
• Insulin lispro protamine (Humalog® Mix 75/25 or 50/50)
• Insulin detemir (Levemir®)
• Insulin glargine (Basaglar®, Lantus®)

Side Effects of Insulin

You may notice some side effects when starting insulin therapy, including:⁹

• Itching, redness, or swelling at the injection site
• Weight gain
• Constipation
• Changes in your skin at injection sites, including fat buildup or fat breakdown

If you notice any of these serious side effects after starting insulin, call your doctor right away:

• Signs of an allergic reaction, including swelling of the face, lips, tongue, throat, or eyes
• Blurred vision
• Sweating
• Abnormal heartbeat
• Muscle cramps
• Weakness

Biguanides

Biguanides are a class of diabetes medications that help stop the liver from converting amino acids (the building blocks of proteins) and fats into glucose. These medications also help cells become more sensitive to insulin and limit the amount of glucose your body absorbs from food. Together, these effects help lower blood sugar in people with T2D.¹⁰

The most commonly known biguanide is metformin (Fortamet®, Glucophage®), which is typically the first medication prescribed to a person newly diagnosed with T2D. Metformin can be prescribed alone as a liquid or tablet. The liquid form is typically taken once or twice daily with meals. The regular tablet is taken two to three times daily with meals, while the extended-release (ER) tablet is taken once daily with a meal in the evening. If you take the extended-release tablet, be sure to swallow it whole — do not crush or chew the tablet.¹¹

Side Effects of Biguanides

The side effects of biguanides like metformin are generally mild. They include:¹¹

• Nausea or vomiting
• Stomachache, indigestion, or bloating
• Diarrhea
• Loss of appetite
• Metallic taste in the mouth
• Headache
• Muscle pain

To help limit the stomach effects of metformin, be sure to take the medication with meals. If you’re vomiting or have diarrhea, drink plenty of fluids to replace what you’ve lost. If these side effects continue after taking the medication for a few weeks or months, talk to your doctor.

Metformin typically doesn’t cause low blood sugar on its own, but it may when combined with other medications such as insulin. With this, it’s important to know the signs of low blood sugar so you can get the treatment you need.

Combination Medications for Type 2 Diabetes

In some cases, your doctor may prescribe you metformin combined with another medication. These are often combined in a single tablet. Examples include:¹¹

• Metformin and sitagliptin (Janumet®)
• Metformin and pioglitazone (Actoplus Met®)
• Metformin and linagliptin (Jentadueto®)
• Metformin and glipizide (Metaglip^TM)
• Metformin and repaglinide (Prandimet®)

The different medications combined with metformin each have other effects on the body that can help boost metformin’s effects.

Sulfonylureas

Sulfonylureas are another class of medication used to treat T2D. They work by stimulating your pancreas to release more insulin and can help increase insulin sensitivity. The more insulin in your bloodstream, the more your cells can use it to take up glucose and use it for energy. While they may sound related to sulfa drugs like antibiotics, sulfonylureas are not the same. If you have an allergy to sulfa drugs, you probably won’t be allergic to sulfonylureas.¹⁰

Examples of sulfonylureas include:

• Glimepiride (Amaryl®)
• Glipizide (Glucotrol®)
• Glipizide ER (Glucotrol XL®)
• Glyburide (Diabeta®, Glynase®)

These medications are typically taken as pills or tablets once or twice daily before meals. Try to take sulfonylureas at the same time every day to keep them effective. Your doctor will likely start you out on a lower dose and increase it over time. However, sulfonylureas may become less effective over time, so you may need a dose adjustment at some point. If you notice your blood sugar level rising over time, be sure to talk to your doctor.

Side Effects of Sulfonylureas

Sulfonylureas are more likely to cause low blood sugar compared to metformin. With this, it’s important to know the signs of low blood sugar in case you need treatment. Other side effects of sulfonylureas include:^12,13,14

• Nausea
• Diarrhea
• Dizziness
• Heartburn
• Feeling full
• Rash or hives
• Itchy, red skin
• Feeling jittery

Drinking alcohol while taking sulfonylureas can make these side effects worse and lead to others, including:

• Face redness or flushing
• Headache
• Nausea or vomiting
• Weakness
• Blurry vision
• Chest pain
• Sweating
• Anxiety
• Difficulty breathing

In some cases, the side effects may be more serious. If you notice any of these symptoms, seek medical attention immediately:

• Signs of an allergic reaction
• Signs of liver problems, including yellowing of the eyes or skin (jaundice), and pain in the upper right portion of the stomach that moves to your back
• Dark urine
• Light-colored stools
• Fever
• Sore throat
• Abnormal bleeding or bruising

Glinides

Glinides, also known as meglitinides, are medications that stimulate beta cells in the pancreas to make and release insulin. This provides more insulin for your cells to use to take up glucose, lowering blood sugar levels.¹⁰

Examples of glinides include nateglinide (Starlix®) and repaglinide (Prandin®). They’re usually taken from 30 minutes before to right before a meal to help limit blood sugar spikes. If you eat an extra meal throughout the day, you should take another dose of your prescription. Glinides work faster than sulfonylureas, but their effects don’t last as long.^15,16

Side Effects of Glinides

Like other T2D medications, glinides can cause low blood sugar levels. Be sure to know the signs of low blood sugar and what treatments to use. Other side effects of glinides you may experience include:

• Flu-like symptoms
• Headache
• Runny nose or congestion
• Cough
• Back pain
• Achy joints
• Constipation or diarrhea

Glinides may also interact with alcohol and other medications, which can cause worsening of side effects. Be sure to talk to your doctor about the amount of alcohol that is safe for you to drink while taking glinides, as alcohol can lower your blood sugar.

Thiazolidinediones

Thiazolidinediones (TZDs), also known as glitazones, are a class of diabetes medications that work in a few different ways. They stop your liver from converting fats and amino acids into glucose while helping your fat and muscle cells better use insulin. Overall, this leads to a decrease in blood sugar. TZDs can be taken alone or combined with metformin for added blood sugar-lowering effects.¹⁷

Currently, there are two TZDs approved by the U.S. Food and Drug Administration (FDA) — pioglitazone (Actos®) and rosiglitazone (Avandia®). The first TZD approved by the FDA was troglitazone (Rezulin®), but it was taken off the market in 2000 for causing serious liver problems in some people. If you’re prescribed pioglitazone or rosiglitazone, your doctor will closely monitor you for any signs of liver problems. However, these medications appear to be safe.¹⁰

TZDs are taken as tablets once or twice daily before a meal. Your doctor may start you out on a lower dose and increase it as needed. You may not see the effects of TZDs for many weeks to months, because the medications work by changing the expression of genes in your liver, muscle, and fat.^18,19

Side Effects of Thiazolidinediones

Some common side effects you may experience while taking TZDs include:

• Muscle pain
• Headache
• Gas
• Cold symptoms, including runny nose and sore throat
• Back pain

The FDA has also issued a warning that TZDs may cause congestive heart failure or make it worse if you already have the condition. This is a condition that occurs when the heart can’t pump blood as well as it used to. Signs of congestive heart failure include:

• Shortness of breath
• Swelling of the hands, arms, legs, ankles, or feet
• Unexpected weight gain in a short amount of time
• Stomach pain or swelling
• Rapid heartbeat
• Fatigue or weakness
• Needing a pillow to prop your head up while sleeping so that you can breathe
• Wheezing or dry cough

Before beginning a TZD, be sure to let your doctor know if you have had any of the following:

• A heart attack
• Sleep apnea
• High blood pressure
• Heart disease
• Coronary artery disease (narrowing of blood vessels that bring blood to the heart)
• Irregular heartbeat (arrhythmia)
• Swelling in your hands, arms, legs, ankles, or feet

Other symptoms that require immediate medical attention while taking a TZD include:

• Signs of liver problems
• Loss of appetite
• Nausea or vomiting
• Changes in your vision
• Signs of an allergic reaction
• Breaking out in a cold sweat
• Problems urinating, or having bloody, cloudy, or dark urine

Dipeptidyl Peptidase-4 Inhibitors

Dipeptidyl peptidase-4 (DPP-4) inhibitors, also known as gliptins, are a newer class of diabetes medications that help lower your blood sugar without causing extreme drops. These medications block the function of DPP-4, an enzyme that’s responsible for breaking down the hormones glucagon-like peptide-1 (GLP-1) and gastric inhibitory peptide (GIP). These hormones are known as incretins.²⁰

Incretins are the body’s natural way to lower blood sugar levels and slow down food leaving the stomach, but DPP-4 breaks them down very quickly. By blocking the enzyme, GLP-1 and GIP are able to stay active in the body, helping reduce elevated blood sugar levels.

The FDA has approved four DPP-4 inhibitors, including:

• Linagliptin (Tradjenta®)
• Alogliptin (Nesina®)
• Sitagliptin (Januvia®)
• Saxagliptin (Onglyza®)

DPP-4 inhibitors are taken once daily with or without a meal. They typically don’t have an effect on weight, but they may help lower your cholesterol levels.

Side Effects of Dipeptidyl Peptidase-4 Inhibitors

In general, DPP-4 inhibitors have very few and mild side effects. These include:^21-24

• Headache
• Runny or stuffy nose
• Painful joints
• Sore throat
• Nausea
• Diarrhea

If you begin to notice any of these serious side effects, seek medical attention immediately:

• Signs of congestive heart failure
• Signs of an allergic reaction
• Severe joint pain
• Peeling, blistering, or itchy skin
• Persistent pain that begins in the stomach and spreads to the back
• Signs of liver problems

Glucagon-Like Peptide-1 Receptor Agonists

GLP-1 agonists, also known as incretin mimetics, are a newer class of diabetes medications that are prescribed to treat T2D that can’t be managed with certain oral medications. These are injectable medications or tablets that mimic the effects of GLP-1 in the body. After you eat, your blood sugar level rises. In response, your body normally makes GLP-1, which helps stimulate the pancreas to release insulin. However, GLP-1 is broken down quickly, so its effects are short-lived.²⁵

GLP-1 agonists work by stimulating the pancreas to make more insulin, which helps lower blood sugar levels. They also help slow digestion and the rate of food leaving the stomach (known as gastric emptying). This helps you feel fuller for longer, so you eat less food. As a result, GLP-1 agonists have been associated with weight loss. Studies show that some of these medications can help you lose between 10 to 34 pounds while making diet and lifestyle changes.

The FDA has approved several GLP-1 agonists for treating T2D, including:

• Dulaglutide (Trulicity®) — injected once weekly at any time, doesn’t need to be around mealtime²⁶
• Exenatide (Byetta®) — injected twice daily one hour before two main meals during the day, around six hours apart²⁷
• Exenatide extended release (Bydureon BCise®) — injected once weekly at any time²⁷
• Liraglutide (Vitctoza®, Saxenda®) — injected once daily at any time²⁸
• Lixisenatide (Adlyxin®) — injected once daily one hour before your first meal of the day²⁹
• Semaglutide, injected (Ozempic®) — injected once weekly at any time³⁰
• Semaglutide, oral (Rybelsus®) — taken once daily by mouth on an empty stomach after waking up with a sip of water; should be taken 30 to 60 minutes before eating your first meal/snack of the day³¹
• Tirzepatide, injected (Mounjaro®) – a new combined GLP-1 and GIP agonist injected once weekly at any time³⁸
  Almost all GLP-1 agonists are injectable medications, while the oral form of semaglutide is taken by mouth. Injectable forms come in pre-filled pens that are injected subcutaneously (under the skin) using a very thin needle. You should rotate injection sites between your upper arm, stomach, and thigh with every dose. If you want to change the day of the week you inject a weekly medication, talk to your doctor about how to safely do so.

Side Effects of GLP-1 Agonists

GLP-1 agonists can cause hypoglycemia (particularly if used with insulin or sulfonyurea medications), so be sure to know the signs of low blood sugar. Other side effects that may occur include:

• Nausea or vomiting
• Diarrhea or constipation
• Feeling fatigued or tired
• Decreased appetite
• Heartburn
• Dizziness
• Sweating
• Feeling jittery
• Headache
• Redness or rash at the injection site
• Pain or burning sensation while urinating
• Cough, sneezing, or runny nose
• Abdominal pain

If you notice any of the following serious side effects, be sure to seek medical attention immediately:

• Signs of an allergic reaction
• Dizziness or fainting
• Signs of liver problems
• Changes in vision
• Rapid heartbeat
• Signs of congestive heart failure
• Extreme thirst or dry mouth

The FDA has also released a warning that GLP-1 agonists may be associated with an increased risk of developing thyroid tumors. This may include certain types of cancer, including medullary thyroid carcinoma (MTC). Before GLP-1 agonists entered human clinical trials, they were tested in animal models. Studies showed that some of these animals developed thyroid tumors, but researchers are unsure of the risk in humans.

Before starting a GLP-1 agonist, let your doctor know if you or anyone in your family has had MTC or if you have multiple endocrine neoplasia syndrome type 2 (MEN 2), a condition that causes tumors to grow on glands in the body. Call your doctor immediately if you begin to notice any swelling or lumps in your neck, trouble swallowing or breathing, or hoarseness.

Sodium-Glucose Cotransporter-2 Inhibitors

Sodium-glucose cotransporter-2 (SGLT2) inhibitors, also known as gliflozins, are newer medications that work differently from other types of T2D treatments. SGLT2 inhibitors work by affecting the kidneys, preventing them from absorbing glucose after it’s been filtered from the blood. This prevents it from re-entering your bloodstream, helping to lower blood sugar levels. Instead, the excess glucose is excreted in urine.³²

Along with their blood sugar-lowering effects, SGLT2 inhibitors have also been shown to help reduce the risk of heart failure and kidney failure in people with T2D. These are common complications caused by high blood sugar levels over time.

FDA-approved SGLT2 inhibitors include:

• Dapagliflozin (Farxiga®)
• Canagliflozin (Invokana®)
• Empagliflozin (Jardiance®)

SGLT2 inhibitors are typically taken once daily as tablets. Dapagliflozin and empagliflozin can be taken with or without food, while canagliflozin is taken before breakfast or your main meal of the day.

Side Effects of Sodium-Glucose Cotransporter-2 Inhibitors

Common side effects of SGLT2 inhibitors include:^33,34,35

• Frequent urination, especially at night
• Constipation
• Increased thirst and dry mouth

Because SGLT2 inhibitors cause you to excrete extra glucose in urine, you may notice some additional side effects affecting your genitals. These are serious and require medical attention. They include:

• Urinary tract infections — having red, pink, brown, or cloudy urine, feeling tired or uncomfortable
• Yeast infections in women — vaginal itching, odor, and white or yellow discharge that may appear lumpy
• Yeast infections in men — swelling, redness, itching, or rashes on the penis, discharge with odor, painful skin around the penis
• Fournier’s gangrene — a life-threatening infection of the skin and soft tissues of the groin area that also occurs more frequently in people taking the SGLT2 inhibitors³⁹

Lifestyle Changes to Treat and Manage Type 2 Diabetes

Medications for T2D tend to work best when paired alongside lifestyle changes, such as diet modifications and exercise. These can help you lose weight, which increases insulin sensitivity. Together, these changes can help you lower your blood sugar and improve your overall health.

Diet Changes for Type 2 Diabetes

Making healthy food choices is a great way to help manage T2D. Your body needs food to fuel it, so choosing healthier options can help you maintain a healthy weight and reduce the risk of other health complications. The American Heart Association (AHA) recommends a diet consisting of:³⁶

• Lean meats, such as chicken, turkey, and some red meats
• Salmon, herring, and other fish at least twice per week for added omega-3 fatty acids
• Deeply colored fruits and vegetables, such as berries, peaches, carrots, and spinach
• Low-fat dairy products, such as milk, yogurt, and cheese
• Whole grains that are rich in fiber, such as brown rice, oatmeal, and whole grain bread and pasta
• Unsalted seeds and nuts

Try to limit sugary options, trans and saturated fats, sodium, and alcohol as much as possible. To help determine how different foods affect your blood sugar levels, you can keep a log of what you eat, and your blood sugar levels about one hour after eating.

Regular Exercise for Type 2 Diabetes

The AHA also recommends at least 150 minutes of moderately intense exercise per week for adults. This is equivalent to around 30 minutes five days a week.³⁶ Research shows that exercise helps you better control your blood sugar levels and increases insulin sensitivity while decreasing your risk of other health complications.³⁷

You don’t necessarily need to go to the gym to exercise — instead, try finding activities you enjoy or can do with another person. These can include:

• Walking around your neighborhood
• Doing housework
• Swimming
• Cycling
• Playing team sports
• Dancing

When you first begin an exercise plan, be sure to start small and work your way up to the intensity that’s comfortable for you. Try to stick to a schedule every day where you make time for a workout or activity that gets your heart rate up.

The Future of Type 2 Diabetes Treatments

As doctors and researchers continue to learn more about T2D, they’ll eventually discover new ways to treat it. Currently, there are several clinical trials underway investigating new therapies for T2D, including new diets and medications.

Learn more about new T2D treatment options and ongoing clinical trials.