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Top 10 Diabetes Treatments You May Have Missed

Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on April 19, 2021.

Are You at Risk for Type 2 Diabetes?

Diabetes and prediabetes are two of the top pressing health issues in the nation. Recent estimates from the American Diabetes Association (ADA) state that about 1.5 million Americans are diagnosed with diabetes every year.

Prediabetes occurs when the blood sugar levels are higher than normal but not yet high enough to be classified as type 2 diabetes. Weight loss and increased exercise can help prevent a type 2 diabetes diagnosis.

Even more concerning is the number of Americans who are at risk for these conditions: it was reported by the ADA that of the 34.2 million adults with diabetes, 26.8 million were diagnosed, and 7.3 million were undiagnosed.

Diabetes remains the 7th leading cause of death in the U.S.

Treatment for Type 2 Diabetes

There's no cure for type 2 diabetes, but patients may be able to manage their condition by eating healthy, staying active through regular exercise, and maintaining a normal weight. But sometimes this just isn't enough.

Medication treatment for type 2 diabetes often begins with oral metformin, a drug that is the backbone of oral diabetes treatment regimens. From there, different drug classes may be added to metformin, and for some patients, the use of injectable insulin may be necessary.

  • Insulin is a hormone the body needs to utilize the glucose (sugar) from food to provide energy for the body.
  • In type 1 diabetes, the pancreas makes no insulin and it must be replaced. In type 2 diabetes, either the pancreas either doesn't make enough insulin, there is resistance to the effects of insulin, or both.

A1C Levels

Diabetes treatments are monitored using a blood sugar target called hemoglobin A1C (HbA1c or just A1C) that gives average blood glucose levels over the past 3 months.

For adults, the American Diabetes Association (ADA) recommends a target HbA1C of below 7%; however, in March 2018, the American College of Physicians (ACP) issued new guidance, suggesting targets between 7% and 8%. Part of the ACP reasoning is to adhere to a more individualized approach to type 2 diabetes treatment. For example, in the elderly, very low blood sugars can be linked with serious health issues, including confusion and fainting.

High blood sugar levels can increase the risk for serious complications due to diabetes such as:

  • vision loss
  • peripheral nerve damage
  • kidney impairment
  • hard-to-treat infections
  • impotence
  • heart disease

However, the latest diabetes news is encouraging. Newer drugs with a positive outcome on heart disease and death, improved monitoring devices and an understanding of how diet and exercise impact diabetes is adding up to a gain in outcomes for patients.

The vast majority of people with type 2 diabetes are living longer lives due to better medications, and a better understanding of the disease and the numerous complications that result from this chronic disease.

In response to the type 2 diabetes epidemic, the U.S. Food and Drug Administration (FDA) continues to approve and improve type 2 diabetes medications and ease dosing regimens for patients.

Here is a selection of some top type 2 diabetes treatments and the latest breakthroughs:

1. Bydureon BCise (exenatide)

AstraZeneca’s Bydureon BCise (exenatide extended-release) is a once-weekly treatment approved for type 2 diabetes. Bydureon BCise is a long-acting form of exenatide, the same active ingredient found in Byetta, but Byetta is given twice-a-day instead of once-a-week. 

The Bydureon BCise injection is used with diet and exercise in people on one or more type 2 diabetes medicines to improve blood sugar control. It is not used as a first-line agent. Bydureon is a glucagon-like peptide 1 (GLP-1) agonist, or incretin mimetic, that binds to GLP-1 receptors to help the pancreas produce more insulin in response to an increase in blood sugar. It is in the same class of drug as Trulicity, Victoza, Rybelsus and Ozempic, among others.

Bydureon BCise consists of a novel, continuous-release microsphere delivery system that is designed to provide consistent therapeutic levels of exenatide. Bydureon BCise comes as a single-dose autoinjector pen. The Bydureon and Bydureon Pen brand are now discontinued in the U.S.

In April 2018, the FDA approved exenatide as an add-on to basal insulin in adults who need extra blood sugar control. In the 28-week study, Bydureon or placebo were evaluated as add-on therapy to insulin glargine, with or without metformin, in adults with type 2 diabetes. Blood sugar control, as measured by the HbA1c, was reduced by 0.9% in the Bydureon group compared to 0.2% in the placebo group. Over 32% of patients in the Bydureon group reached an HbA1c of <7.0% compared to 7% of patients in the placebo group, a significant effect.

Low blood sugar (hypoglycemia) can be a problematic side effect when Bydureon BCise is used with insulin or insulin secretagogues like glyburide, glipizide or glimepiride. The dose of these agents may need to be reduced when combined with Bydureon BCise.

Symptoms of low blood sugar include a headache, sweating, shaking, anxiety, fast heartbeat, irritability, rapid breathing, or a confused state. Patients should learn to recognize these effects so they can treat low blood sugar with a carbohydrate source.

Other common side effects with exenatide have included:

  • nausea
  • vomiting
  • diarrhea
  • injection site itching
  • injection site nodules

As with other GLP-1 agonists, Bydureon BCise labeling contains a Boxed Warning, the FDA's most stringent safety labeling, about the increased risk of thyroid cancer, as seen with animal studies; however, the risk in humans is not known.

Do not use Bydureon BCise if you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. 

This is not a full list of warnings or side effects, so speak with your doctor before you start treatment.

2. Humalog (insulin lispro)

Insulin is a hormone that works to lower levels of blood glucose (blood sugar) and is found either naturally in the body or man-made and given by injection or inhalation. The development of life-saving insulin for people with diabetes is one of the top medical breakthroughs in the history of medicine.

Humalog (insulin lispro), from Eli Lilly  is one of several man-made insulins for patients with diabetes. Humalog is known as a “fast-acting” insulin that starts to work about 15 minutes after injection, peaks at one hour, and it keeps working for 2 to 4 hours. It is typically given within fifteen minutes before a meal or immediately after a meal and may be used in regimens with an intermediate- or long-acting insulin for insulin coverage throughout the day.

Humalog is used to improve blood sugar control in both patients with type 1 diabetes, who do not produce insulin from the pancreas, and type 2 diabetes, who still produce insulin (but it’s not used efficiently). As blood sugar levels rise with meals, those with diabetes may need insulin injections at mealtime if their blood sugar is not controlled with other diabetes medications.

Hypoglycemia (low blood sugar) is the most common side effect with insulins, including Humalog. Always have a quick source of some type of sugar available for hypoglycemia episodes, for example:

  • jelly beans
  • glucose tablets
  • fruit  juice.

The Humalog Junior KwikPen (100 units per mL) is also available for children as a prefilled 3 mL disposable pen with half-unit dosing. This more precise dosing is an advantage for children with diabetes who require smaller doses. Each turn of the dose knob dials 0.5 (½) unit of insulin. You can give from 0.5 (½) to 30 units in a single injection. The maximum dose per injection is 30 units. Another advantage - no refrigeration is needed after you start using it.

Admelog (insulin lispro) is the first rapid-acting insulin approved as a “follow-on” (or biosimilar-type product) to Humalog. Costs with Admelog may be lower than other insulin lispro products. In June 2020, Lyumjev (insulin lispro-aabc injection) from Eli Lilly was the second approved follow-on to Humalog.

3. Jardiance (empagliflozin)

Death from heart disease is 70% higher in diabetics compared to those without diabetes. So controlling heart (cardiovascular) disease in patients with type 2 diabetes in an important goal.

Jardiance (empagliflozin), from Boehringer Ingelheim and Eli Lilly, is classified as a sodium glucose co-transporter-2 (SGLT2) inhibitor and was originally approved in 2014 to improve blood sugar control (HbA1c) in adults with type 2 diabetes alongside diet and exercise. Jardiance is also approved to lower the risk of cardiovascular death in adult patients with type 2 diabetes and heart disease.

Other SGLT-2 inhibitors on the U.S. market include: Farxiga (dapagliflozin), Invokana (canagliflozin) and Steglatro (ertugloflozin).

Jardiance side effects may include:

  • dehydration and low blood pressure that can result in dizziness and fainting
  • yeast infections
  • low blood sugar with insulin or insulin secretagogues
  • elevation in LDL cholesterol
  • increased risk for urinary tract infections
  • impaired kidney function.

Other combination products that contain empagliflozin are: Glyxambi (empagliflozin and linagliptin), Synjardy (empagliflozin and metformin) and Synjardy XR, and Trijardy XR (empagliflozin, linagliptin and metformin).

4. Lantus (insulin glargine)

While short-acting insulins like Humalog are used at mealtimes, long-acting basal insulins work to keep the blood sugar levels even throughout the day. Lantus (insulin glargine), from Sanofi, is used to treat adults with type 2 diabetes and adults and children 6 years and older with type 1 diabetes.

Lantus provides a slow, steady release of insulin and helps to manage the blood sugar levels between meals and overnight.

  • The onset of Lantus is usually within 1 to 3 hours, with a duration of 24 hours.
  • Due to its long duration of action it is injected subcutaneously (under the skin) just once a day, at the same time each day.

Some patients use a rapid acting human insulin or an oral diabetes medication in combination with Lantus.

  • Lantus comes as a 100 units/mL in either 10 mL vials or as the 3 mL SoloStar prefilled pen.
  • With the SoloStar pen, you dial the dose you need on the pen and use the push button for injection.

In June 2020, Semglee (insulin glargine) from Mylan and Biocom was FDA-approved as a more affordable follow-on to Lantus, and is approved for the same uses. Semglee has an identical amino acid sequence to Lantus (insulin glargine). Semglee 100 units/mL (U-100) injection is available as two dose forms: a  10 mL multi-dose vial and 3 mL single-use prefilled pen.

5. Soliqua 100/33 (insulin glargine and lixisenatide)

Sanofi’s Soliqua 100/33 injection (insulin glargine and lixisenatide) is a combination of insulin glargine 100 Units/mL and lixisenatide 33 mcg/mL, a glucagon-like peptide-1 (GLP-1) agonist. The two drugs combined now mean one injection for the patient with type 2 diabetes, instead of two. That's a big improvement.

Soliqua 100/33 combines a long-acting, basal insulin with a GLP-1 (glucagon-like peptide-1) receptor agonist to help control blood sugar and lower HbA1c. It is used with diet and exercise to control blood sugar in adults with type 2 diabetes inadequately controlled on basal insulin (less than 60 units daily) or lixisenatide. It comes as a single dose, pre-filled pen and is given as a once-daily injection.

  • Lantus is a long-acting basal insulin that provides a steady insulin release to manage blood sugar levels between meals and at bedtime.
  • Adlyxin is a GLP-1 agonist that helps the pancreas produce more insulin in response to an increase in blood sugar and controls glucose production from the liver.

In studies, Soliqua 100/33 showed better HbA1c lowering (average blood sugar over time) versus Lantus with 55% of patients achieving a target of less than 7% at 30 weeks, compared to 30% with Lantus alone. Hypoglycemia rates were similar in both groups.

The most common side effects with Soliqua include low blood sugar, nausea, diarrhea, respiratory tract infections, and headache.

In 2019, the FDA expanded the uses for Soliqua 100/33 to include type 2 diabetes patients uncontrolled on oral antidiabetic agents such as metformin and / or a second oral antidiabetic therapy.

6. Toujeo (insulin glargine)

Long-acting insulin injections help patients with diabetes control their blood sugar levels over a 24-hour period. Sanofi’s Toujeo (insulin glargine) is the same active ingredient that's in Lantus. Toujeo is a once-daily, long-acting basal insulin for adults with type 1 or type 2 diabetes.

In the clinical trials evaluating Toujeo, all of the primary study endpoints were met by demonstrating similar blood sugar control with Toujeo as compared to Lantus. Toujeo’s onset is within 6 hours, and it has a duration of up to 36 hours, reaching a steady blood level by about day five.

The most common side effects reported for Toujeo (excluding low blood sugar) included the common cold and upper respiratory tract infections.

The Toujeo SoloStar pen can make life easier for patients with type 2 diabetes, possibly lowering the number of injections per day as well as the number of pens used those who need higher insulin doses.

Toujeo is available in 2 disposable prefilled pens:

  • ‚ÄčToujeo SoloStar contains 450 units of Toujeo U-300. It delivers doses in 1 unit increments and can deliver up to 80 units in a single injection.
  • Toujeo Max SoloStar, approved in March 2018, contains 900 units of Toujeo U-300, more insulin than any other long-acting insulin pen. It delivers doses in 2 unit increments and can deliver up to 160 units in a single injection. It is recommended for patients requiring at least 20 units per day.

7. Trulicity (dulaglutide)

Trulicity (dulaglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist for the treatment of type 2 diabetes. It is in the same class of drug as Bydureon BCise, Victoza, Rybelsus and Ozempic, among others.

Trulicity, from Eli Lilly, is approved as a once-weekly subcutaneous (under the skin) injection used to improve blood sugar levels, along with diet and exercise, in adults with type 2 diabetes. Trulicity is not recommended as the first choice of medicine for treating type 2 diabetes, but may be added to other oral agents. It's use has also been expanded to help reduce the risk of serious heart problems such as heart attack or stroke in adults wth type 2 diabetes and heart disease.

Trulicity comes as a pen device with an automatic injector. Once-weekly dosing may be a big advantage for many patients. Another advantage to GLP-1 receptor agonists is a low risk for low blood sugar (hypoglycemia), especially compared to insulin or sulfonylureas.

GLP-1 receptor agonists should not be used by anyone with a personal or family history of certain types of thyroid cancer. A boxed warning exists for all GLP-1 receptor agonists for possible thyroid tumors, including cancer.

Common side effects with Trulicity include:

  • nausea
  • vomiting
  • diarrhea
  • stomach pain
  • decreased appetite.

8. Victoza (liraglutide)

Victoza (liraglutide) from Novo Nordisk is also a glucagon-like peptide-1 (GLP-1) receptor agonist (incretin mimetic) indicated to improve glycemic control in adults with type 2 diabetes mellitus. It is in the same class of drug as Trulicity, Ozempic, Rybelsus and Bydureon BCise.

Type 2 diabetes patients have a four times greater risk of developing heart disease, which is the leading cause of disease and death in patients with type 2 diabetes.

Although Victoza was originally approved in January, 2010, in 2017 it gained a new labeled indication to reduce the risk of heart attack, stroke and cardiovascular (CV) death in adults with type 2 diabetes and established heart (cardiovascular) disease. Victoza demonstrated a life-saving benefit that included a 22% reduction in cardiovascular death and a 15% reduction in all-cause death.

The most common side effects leading to the study discontinuation of Victoza were gastrointestinal (stomach) events, which are common with GLP-1 receptor agonists. The most common side effects of Victoza are headache, nausea and diarrhea.

Victoza is available as 0.6 mg (for initial titration), 1.2 mg or 1.8 mg injection in pre-filled, multi-dose pens. Each 3 mL pen contains 6 mg/mL of liraglutide. Victoza is used once daily each day, and it can be used at any time of the day.

9. Ozempic & Rybelsus

Ozempic (semaglutide) is a glucagon-like peptide-1 (GLP-1) analog from Novo Nordisk. It is used in patients with type 2 diabetes as an adjunct to diet and exercise to improve blood sugar control, and also to to reduce the risk of events like a heart attack, stroke or death in adults with established heart disease.

  • Ozempic is a subcutaneous (under the skin) injection given once-a-week and comes as a pre-filled, disposable, single-patient-use injection pen.
  • As with other GLP-1 analogs, you should not use Ozempic if you have multiple endocrine neoplasia type 2 (tumors in your glands), a personal or family history of medullary thyroid cancer, insulin-dependent (type 1) diabetes, or diabetic ketoacidosis.
  • In studies, the most common adverse reactions reported in 5% or greater of patients treated with Ozempic were: nausea, vomiting, diarrhea, abdominal pain and constipation.

Rybelsus (semaglutide), also from Novo Nordisk, was approved in Sept. 2019 as the first oral GLP-1 agonist in the U.S. It is a novel oral product of the injectable form of semaglutide (Ozempic). 

Rybelsus is given as an oral tablet once a day. Take your Rybelsus dose at least 30 minutes before the first food, beverage, or other oral medications of the day with no more than 4 ounces of plain water only.

The most common side effects reported in at least 5% of patients taking Rybelsus are nausea, stomach area pain, diarrhea, decreased appetite, vomiting and constipation.

10. Steglatro, Segluromet, and Steglujan (ertugliflozin)

As we have seen, patients with type 2 diabetes often need a combination of medications to control their blood sugar.

Pfizer and Merck’s new SGLT2 inhibitor Steglatro (ertugliflozin), as well as two new combination agents that contain ertugliflozin: Segluromet (ertugliflozin and metformin), and Steglujan (ertugliflozin and sitagliptin) have been FDA-approved. These are all oral agents used together with diet and exercise to improve blood sugar control in adults with type 2 diabetes mellitus.

In Phase 3 studies for Steglatro approval, Steglatro was studied alone and in combination with metformin and/or sitagliptin, as well as with insulin and a sulfonylurea. Steglatro on top of metformin plus sitagliptin resulted in significant A1C reductions of 0.7% and 0.8% compared with 0.2% for placebo, and weight loss of roughly 6.2 to 6.6 pounds.

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Sources

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.