Is This Glucose-Lowering Drug the Right One for You?

Many new glucose lowering drugs for people with type 2 diabetes have been introduced over the last 30 years. In addition to various types of insulin, there are now 8 different classes of drugs that are available in Canada and that have been approved for type 2 diabetes. These include:

1. Metformin
2. Acarbose
3. Sulfonylurea drugs (mainly gliclazide)
4. Meglitinide drugs (nateglinide or repaglinide)
5. Thiazolidinediones (mainly pioglitazone)
6. The DPP4 inhibitors (mainly sitagliptin and linagliptin)
7. The SGLT2 inhibitors (empagliflozin, dapagliflozin, and canagliflozin)
8. GLP-1 related drugs agonists (mainly semaglutide, dulaglutide, and tirzepatide)

Each class of drug lowers glucose in a different way, and each has a different side effect profile. Two of the classes (the SGLT2 inhibitors and the GLP-1 related drugs) are approved for reducing heart attacks, strokes, kidney disease, and other serious health outcomes in people with diabetes.

So how can health care providers and patients best choose the drug or combination of drugs that is right for them?

Every patient is different. What works for one person may not work for another. This means that it’s impossible to develop any hard rules regarding which drugs to choose. There are, however, some easy-to-understand considerations that are captured by the answers to the following questions.

1. How high is the risk that a particular individual will have a heart attack, heart failure, stroke, kidney disease, or other serious health outcomes over the next 10 years? The higher the risk the more appropriate is a drug such as an SGLT2 inhibitor, or a GLP-1 related drug.
2. Does the individual currently have evidence of heart failure or kidney disease? If the answer is yes, it would be appropriate to use an SGLT2 inhibitor either alone or together with a GLP-1 related drug.
3. What other drugs have been tried and are no longer effective or cannot be tolerated? Clearly, drugs that don’t work or that cannot be tolerated should not be used.
4. What combination of drugs will minimize the total number of drugs that are taken? It is generally better to use fewer drugs than more drugs whenever possible.
5. Is there a product that combines two drugs into one pill or capsule? Most people prefer taking fewer pills even if the number of drugs within the pills is the same.
6. How high is the glucose level or hemoglobin A1c? the higher the level the more appropriate insulin would be as a therapy to add as a next therapy.

There are clearly other questions that are important to both healthcare providers and people with diabetes as they choose the best therapy for them. Ongoing conversations with qualified providers can help identify the drug combination that is most suited to any individual.

About the author

Hertzel Gerstein

Hertzel is an endocrinologist and professor at McMaster University who is in high demand as a speaker, advocate, and educator on diabetes-related topics. His research focuses on using large, international randomized trials to identify and test new ways of preventing type 2 diabetes, reducing serious health outcomes like strokes and death, and achieving type 2 diabetes remissions.