There is no single best medication for every person with type 2 diabetes. Treatment may include oral tablets, injections, insulin, lifestyle changes, or a combination of approaches, and medication needs may change as diabetes progresses. The choice can depend on blood-glucose levels, heart or kidney disease, weight goals, risk of low blood sugar, side effects, cost, insurance coverage, and personal preferences.
Metformin
Metformin reduces glucose production by the liver and helps the body respond better to insulin.
It remains a commonly used treatment because it is effective, familiar, and available as a generic.
Possible side effects include:
- Nausea
- Diarrhea
- Stomach discomfort
- Reduced appetite
Taking it with food may improve tolerability. Extended-release formulations may be easier for some patients to tolerate.
Kidney function should be reviewed because metformin may not be appropriate at certain levels of kidney impairment.
GLP-1 Receptor Agonists
Examples include:
- Semaglutide
- Dulaglutide
- Liraglutide
Related dual-action medicines include tirzepatide.
These medications can:
- Increase insulin release when glucose is elevated
- Reduce glucose production
- Slow stomach emptying
- Reduce appetite
- Support weight loss in many patients
Some medications in these classes also have cardiovascular or kidney-related benefits for appropriate patients.
Common side effects include nausea, vomiting, diarrhea, constipation, and reduced appetite.
The American Diabetes Association advises using FDA-approved products and recommends against non-FDA-approved compounded GLP-1 and dual GIP/GLP-1 products due to uncertainty about their content and concerns about safety, quality, and effectiveness.1
SGLT2 Inhibitors
Examples include:
- Empagliflozin
- Dapagliflozin
- Canagliflozin
- Ertugliflozin
SGLT2 inhibitors cause the kidneys to remove more glucose through the urine.
Some products may also provide heart-failure or kidney benefits in appropriate patients.
Possible concerns include:
- Genital yeast infections
- Increased urination
- Dehydration
- Low blood pressure
- Rare but serious ketoacidosis
- Urinary symptoms
Patients may receive instructions about temporarily holding these medications during surgery, prolonged fasting, or serious illness.
Sulfonylureas
Examples include:
- Glipizide
- Glimepiride
- Glyburide
Sulfonylureas stimulate the pancreas to release more insulin.
They can lower glucose effectively but may cause:
- Low blood sugar
- Weight gain
- Dizziness or weakness related to hypoglycemia
Meal timing matters. Patients should know how to recognize and treat low blood sugar.
DPP-4 Inhibitors
Examples include:
- Sitagliptin
- Linagliptin
- Saxagliptin
- Alogliptin
DPP-4 inhibitors help the body increase insulin and decrease glucose production in a glucose-dependent manner.
They are generally weight-neutral and have a relatively low risk of hypoglycemia when used without insulin or a sulfonylurea.
Dose adjustments may be needed for some products based on kidney function.
Thiazolidinediones
Examples include:
- Pioglitazone
- Rosiglitazone
These medicines improve the body's sensitivity to insulin.
Potential concerns include:
- Weight gain
- Fluid retention
- Worsening heart failure
- Bone-fracture risk
- Delayed onset of full effect
They are not appropriate for every patient.
Insulin
People with type 2 diabetes may need insulin when:
- Blood glucose is significantly elevated
- Other medications are insufficient
- The body is no longer producing enough insulin
- The patient is hospitalized
- The patient is pregnant
- Serious illness or surgery changes glucose control
Needing insulin does not mean the patient failed. Type 2 diabetes can progress over time, and treatment requirements commonly change.
Can Diabetes Medications Cause Low Blood Sugar?
The risk differs by medication.
Insulin and sulfonylureas have a more significant risk of hypoglycemia. The risk can increase with skipped meals, increased activity, alcohol, dosing errors, or reduced kidney function.
Symptoms may include:
- Shaking
- Sweating
- Hunger
- Dizziness
- Confusion
- Rapid heartbeat
- Weakness
Patients at risk should have an individualized plan for recognizing and treating low blood sugar.
The Bottom Line
Diabetes medications do more than lower a number on a glucose meter. The best treatment plan considers glucose control, heart and kidney health, weight, hypoglycemia risk, affordability, and the patient's daily life.
Frequently Asked Questions
Is metformin still the first choice for type 2 diabetes?
Metformin remains a commonly used first treatment because it's effective, familiar, and available as an affordable generic, though newer classes like GLP-1 receptor agonists and SGLT2 inhibitors may be preferred earlier for patients with heart or kidney disease.
Is compounded semaglutide safe to use instead of Ozempic or Wegovy?
The American Diabetes Association recommends against non-FDA-approved compounded GLP-1 products due to uncertainty about their content and concerns about safety, quality, and effectiveness.
Does needing insulin mean my diabetes treatment failed?
No. Type 2 diabetes can progress over time regardless of how well a patient follows their treatment plan, and needing insulin is a common, expected part of that progression for many patients.
Which diabetes medications are most likely to cause low blood sugar?
Insulin and sulfonylureas carry the most significant hypoglycemia risk. Risk increases with skipped meals, increased activity, alcohol, dosing errors, or reduced kidney function.
The best treatment plan considers glucose control, heart and kidney health, weight, hypoglycemia risk, affordability, and the patient's daily life — not just the number on a glucose meter.
References
- American Diabetes Association. The American Diabetes Association Announces Statement on Compounded Incretin Products. diabetes.org/newsroom/press-releases